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STATE OF CALIFORNIA e� v STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH F ITY/SITE MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANEN ED SITE ONE REM O 2 INTERIM PERMIT 4 AMENDED PERMIT E-3 e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION 11 ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS A�STC OSS STREET PARCELs(OFRDI L) �i CRY NAME STATE ZIP 010D / SITE NES WITH AR DE Box CA -5VL TO INDICATE O CORPDRATioN ED INDIVIDUA I:1 PARTNERSHIP ED LNBTRIAUKY 0 COUNrY4MNCY' 0 STATE-AGENCY' [::] FEDERAL-AGENCY' N owner of UST Is a pubbc agency,corrplela the following:name of SYPBNMor of division.seCIOn.a office which Operates the UST TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN I N OF TANKS AT SITE I E.P.A. I.D.#(ap6mg 0 3 FARM Q 4 PROCESSOR 0 6 OTHER RESERVATION OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional GAYS: A E(LAST,FIRST) PHONE#j.H r,.EA CODE DAYS: NAME MST,FIRST) PHONE•WITH AREA CODE NIGH : NAME LAST FIRST) PHONE A WITH AREA COD NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS - ✓box bindi ED INDIVIDUAL (] LOCAL-AGENCY E:3 STATE-AGENCY O CORPORATION 0 PARTNERSHIP O COUNrYAGENCY O FEDEMLAGENCY CITU NAME eTATE ZIP CODE PHONE#W17H AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box biMlcaN [7D INDIVIDUAL O LOCAL-AGENCY I1 STATE-AGENCY O CORPORATION 7] PARTNERSHIP 0 COUNfYADENCY = FEOERALAGENCY 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 [4T4--]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box birdkme Q 3 SELF INSURED 0 2 GUARANTEE (]3 INSURANCE A SURETY BOND 5 LETTER OF CREDIT =8 EXEMPTION 0 a OTHER 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: IL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AWCORRECT OWNER'S NAME(PRINTED A SIGNED) OWNER'S TITLE DATE MONTKDAYNEAR \1 LOCAL AGENCY USE ONLY COUNTY# / JURISDICTION If ® F4c.41 32115-10 LOCATION COQE -OPTIONAL CENSUS T1,-GPjpNAL 9l1PVISOR-DISTRICT CODE -OV' - 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 WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(3'93) FCRM3Ali7