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a STATEOFCAUFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH ACIUTYISITE MARK ONLY ❑ I NEW PERMIT ❑ D RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I.N I. FAC LfTY/SITE INFORMATION & ADDRES -(MUST BE COMPLETED) AT OBA ACRITY NAME I NAME OF OP O D NEAREST CROS53 EET PARCEL 0(OPTIONW CI NAME [Y� STATE LP Com, SITE PHO E i AR CODE CA v` ✓ BDx TOINDICATE CORPORATION Q INDIVIDUAL 0 PARTNERSHIP DISTRICTS'T$�Y O COUNTY-AGENCY' O STATE-AGENCY' 0 FED1AALAGENCY' I amen of UST Is a public agency,oo plMe Ne ICYowmg:narte 01 Superviml Of division,aeulion,W 011101,which OPOIN"IM UST TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR Q RE' IF INDIAN i OF T AT SITE E.P.A. I.D.a(cptwW) TON O FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•apGpnal DAYS: NAME(LAST,FIRST) PHONE a WTH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION• UST BE COMPLETED NAME _ CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS .1but W&M 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY l pAt 0 CORPORATION 0 PARTNERSHP O COUNIY-AGENCY I] FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bwputlpW O INDIVIDUAL O WCALAGENCY Q STATE-AGENCY 0 CORPORATION a PARTNERSHIP a COUNrY.AGENCY O FEDEML-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ F4-F4] V. 4- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓bo[p YIdlcic O I SELF-INSURED 0 2 GUARANTEE O J INSURANCE 0 0 SURETY BOND O S LETTER OF CREDIT O B EXEMPTION Q Ip OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner u.niesy6x I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.❑ IN.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRI SIGNED) OWNER'S TITLE DATE MONTHIDAYIYEAR LOCAL AGENCY USE ONLY —'7,0 COUNTY JURISDICTION i P9FACILITY i 3a LOCATION CODE -OPTp CENSUS TRACTa -OP ypL SUPVL40R-DISTRIT ATF. n THIS FORM MUST BE AMED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS AI CIIIANGE OF SITE WOW71ON ONLY, OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IIMLEMENTING THE UNDERGROUND STORAGE TANK REGIAATKINB 22AR7 FORM A 0" l