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�.. s °'; STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ?.,� .e; UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A s° _ , COMPLETE THIS FORM FOR EACH FACILrrY1SrTE :tl MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED.SITE _ ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE �Oma I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR Dominqo ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 49 CITY NAME I STATE ZIP CODE SITE PHONE#WITH AREA CODE CA ✓Box 0 CORPORATION 0 INDIVIDUAL PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' TO INDICATE DISTRICTS ##nmrt#IUSTkspu agmy.wmpWoft Wmilg name 01 sWervsnrel tlN jon,seaimera me khe Wffi the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTORgE a IF INDIAN #OF TANKS AT SITE E.P.A. L D.#(GPM10 ❑ 3 FARM ❑ d PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ Wsbinkel# ED INDIVIDUAL O LOCAL-AGENCY D STATE-AGENCY O CORPORATION 0 PARTNERSHIP O OOUNtY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CME OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxt,ndWe 0 INDIVIDUAL O LOCAL-AGENCY D STATE-AGENCY 0 CORPORATION 0 PARTNERSHIP 0 COIMIY-AGENCY D FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#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 ✓o°vmlMirate O t SELF-INSURED 0 2 GUARANTEE O 31NSURANCE O#SURETY BOND 0 5 LETIEROFCREDIT O e EXEMPTION 0 STATEFUND (]8STATE FUND&CHIEF FINANCIAL OFFICER LETTER 0 B STATE FUND A CERTIFICATE OF DEPOSIT 010 LOCAL GOVT.MECHANISM 0880THER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing Will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ 111.❑ 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 MONTH/DAYNEAR LOCAL AGENCY USE ONLY CODE # JURIS # FACT® 3/1115'$, LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 31I? M 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 FORM VATH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND JSTORAGE TANK REGULATIONS FORM A(S-95) _ . 4.0 \.0&