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STATE OF CALIFORNIA �4.� STATE WATER RESOURCES CONTROL BOARD a vim, e UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A :e - COMPLETE THIS FORM FOR EACH FACILITY/SITE '� ' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) DBA OR FACT NA E / I NAME OF OPERATOR ADDRESS j NEAREST CROSS PARCEL#(OPTIONAL) CITY NAME •ve/lr STATE ZIP COD SITE PHONE N WITH AREA CODE CA ✓ BOX CORPORATION 0 INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY' D STATE-AGENCY' O FEDERAL-AGENCY' TO INDICATE DISTRICTS I owner#UST is apOkageaq,omplete the la9owng:re olsWp oroiEivL ,me oroftAirA9pemles Na UST TYPE OF BUSINESS ❑ 1 GAS STATION O E 2 DISTRIBUTOR ❑ RE IRVATION M OF TA KS AT SITE E.P.A. I.D.M(aprioneq 3 FARM A PROCESSOR A 5 OTHER ORTRUSTLANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DA : NAME(LAST.FIR T) HONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE r NIGHTS: NAME(VAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE p N II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFD) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ kf to rx a'e 0 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY O CORPORATION =PARTNERSHIP Q COUNTY-AGENCY D FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWN R AAA „/ CARE OF ADDRESS INFORMATION MAILING STREET DDRESS/A , ✓ box K irdicaN INDMDUAL LOCAL-AGENCY 0 STATE-AGENCY O CORPORATION O PARTNERSHIP I� COUNTY-AGENCY = FEDERAL-AGENCY CIN NAME ! STATE ZIP t* 0 PHONE t WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- ba5oo q V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓boa to inQrale 1� 1 SELF-INSURED O 2 GUARANTEE = 3 INSURANCE O A SURETY BOND 0 5 LETTEROFCREDR =S EXEMPTION 1=7 STATE FUND &STATE FUND&CHIEF FRLINCIN OFFICER LETTER = 9 STATE RIND 6 CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM 1= 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or If is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ II.❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTW'DAYNEAR LOCAL AGENCY USE ONLY Z L) a3 3 COUNTY M JURISDICTION 0 FACILITY F LOCATION E -OPTIONAL CENSUS TRACT# -OPIONAL SUPVISDR-DI^,ATRICTOCO) OPTIONAL s CC//✓/#!y-M�/� OV THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FOR`TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRI- 3 STORAGE TANK REGULATIONS FORM q(E95) -.Ae