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�✓ a O 1r STATE OF CALIFORNIA J�x ', STATE WATER RESOURCES CONTROL BOARD +,,,� e a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A > - COMPLETE THIS FORM FOR EACH FACILITY/SITE In MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT a TEMPORARY SITE CLOSURE i5 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACIUTY NAME NAMED OPERATOR ADD SS pa NEAREST CROSS STREET PARCEL#(OPTIONAL) E CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CA ✓Box O CORPORATION D INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' [::I FEDERAL-AGENCY' TO INDICATE DISTRICTS X~o(USTtapubkapenq,ompMe Nwbkwhg:re o[supeMord Bwison,sec ionoroffarewtkhmOntbe UST TYPE OF BUSINESS ❑ i GAS STATION ❑ 2 DISTRIBUTOR O ✓IF INDIAN J#OFTANKS AT SITE E.P.A. I.D.#(OPIAO 1) RESERVATION Q 3 FARM Q 4 PROCESSOR Q 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 N 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 ✓ box w ink le [___1 INDIVIDUAL ED LOCAL AGENCY 0 STATE-AGENCY D CORPORATION Q PARTNERSHIP O COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bexloidicMe INDIVIDUAL (] LOCAL-AGENCY Q STATE-AGENCY D CORPORATION D PARTNERSHIP E::] COUNTY-AGENCY 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-T4--]-I- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓Doam e6mM [:::] s SELF-INSURED O 2 GUARANTEE [--13 INSURANCE [::]a SURETY BOND CD 5 LETIEROFCREDR E::]a EXEMPTION E3 7 STATE FUND O3 STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9STATE R)ND&CERnIRCATEOFDEPOSIT OIDLOCAL GOVT.MECHANISM O99OTHER 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.❑ U.O III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BESTOF MY KNOWLEDGE,IS TRUEAND CORRECT TANK OWNERS NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAY/YEAR LOCAL AGENCY USE ONLY COUNTY k JURISDICTION M FACT m 7,fA5G Yol3hICE1 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL AIZ 9P 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 FO1 4 WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGr"IND STORAGE TANK REGULATIONS FORM A(6-95) `�