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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ``.. L/ � /UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORNI A COMPLETE THIS FORM FOR EACH FACIUTYISITE MARK ONLY ❑ I NEW PERMIT ❑1 D RENEWAL PERMIT 5 CNANGE OF INFORMATION ❑ T PERMANENTLY CLO ONE REM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE nd I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) CBAORFACILITYNAME I NAMEOFOPEAATOR 1114 Ara G ADDRESS I NEARESTCROSS STREET PARCELS(OPTIMAL) CITY NA'AE STATE ZIP CODESITE PHONE t WITH AREA COO S b CA 9 S20Box _ 6 TOMXATE Q CORPORATION INOIV AL =PARTNERSHIP C LOCAL.AGENCY Q COUIRYAGENCY C= STATE AGENCY OSTRICTS O FEDERAL AGENCY TYPE OF BUSINESS I GAS STATION 2 DISTRIBUTOR ❑ ✓ IF INDIAN is OF TM1KS AT SITE E.P.A. L D.•(oplunyJ Q G FARM 0 A PROCESSOR Q S OTHER RESERVATION OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS:NAME(LAST,FIRST) PHONE f WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE5;WITH AREA CODE NIGHTS: NAME(LAST,FIRST) Pu f H c nc 11. PROPERTY CWNER INFORMATION• MUST BE COMPLETED NAME I CARE OF ADDRESS INFORMATION MALING CR STREET ADDRESS ✓ OOA E+IaieAY INDIVIDUAL Q LOCAL.AGENCY STAT-c.AGENCY Q COflPoRATION Q PARTNERSHIP Q COUNTYAMNCY FEDERALAGENCY CITY NAME STATE I ZIP CODE PHONE t WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ CP+auacat O INDIVIDUAL a LOCAL-ADENCY CD STATE.AGENCY O CORPORATION Q PARTNERSHIP 0 COUNTYAGENCY Q AMPALAGENCY CITY NAME STATE ZIP CODE PHONE•WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if ques5ons arise. TY(TK) HQ F4747,- V. 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ' ✓Oof ltillMN 1 SELF-INSURED CI 2 GUARANTEE Q 1 INSURANCE D OT N O f SURE 5 LETTER OF CREY 90N0 Cj 8 EXEMPTION � W OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ IL❑ IN.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANTS NAME(PRINTED 6 SIGNATURE) APPLICANT'S TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY rN COUNT'6 JURISDICTION x O FACIL TY a O J `-I`Ll t to I[ M LOCATION CODE •OPTIONAL f CENSUS TRACT t -OPTpNAL SUPVISOR-DISTR T COOS -OPTpNAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(S-91) Fg10P17A-5