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_ C STATE OF CALIFORNIA J STATE WATER RESOURCES CONTROL BOARD ;�v�r UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A n , '° COMPLETE THIS FORM FOR EACH FACILRYISITE m e MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE ONE REM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT A 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME STATE CA _611 ZIP CODE SITE PHONE W TH AREA C pE 71 ✓BOX 0 CORPORATION 0 INDIVIDUAL [�71 PARTNERSHIP L::]LOCAL-AGENCY O COUMV-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' TO INDICATE DISTRICTS •9 aem of UST Is a public-A Y,comPme the fulbwng r d:uperncwd d'aision,section or ORIN whit operates the UST TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓IF INDIAN 1#OF TANKS AT SITE I E.P.A. 1.D.#(#phonal) RESERVATION Q 3 FARM Q ct 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 N WITH AREA CODE NIGHTS: NAME(LAST RST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE It. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ b>etoindmee Q INDIVIDUAL ED LOCAL AGENCY Q STATE-AGENCY jeo 15 O CORPORATION =PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE LP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bus b nd'aate O INDIVIDUAL LOCAL AGENCY STATE-AGENCY CORPORATION O PARTNERSHIP COUNTY-AGENCY Q 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 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓We tdcate O I SELF.INSURED O 2 GUARANrEE O 3 INSURANCE =A SURETY BOND O 5 LETTER OF CREDIT =8 EXEMPTION l=7 STATE FUND 8 STATE FUND B CHIEF FINANCIAL OFFICER LETrER Q 9 STATE RIND 6 CERTIFICATE OF DEPOSIT O 19 LOCAL GOVT.MECHANISM ED 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ II.Q III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK OWNERS NAME(PRINTED a SIGNATURE) TANK OWNERS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY x JURISDICTION N FACILITY 0 m 4K� Izlzq(lam LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 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• RM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDER11ROUND STORAGE TANK REGULATIONS FORM A(6-95)