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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , € COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION O T PERMANENTLY CLOS ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE rJ, I. FACILTTYISITE INFORMATION&ADDRESS-(M ST BE COMPLETED) DBAOR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PNICELN(OPFIOW CITY NAME STATE ZIP / SITE PHONE a WITH AREA CODE Ca S .1 Box TO OCATE CORPORATION Q INDIVIDUAL =PARTNERS14P (� LOCAL-AGENCY O COUNTYAGENCY' STATE-AGENCY' O FEDERALAGENCY' DISTRICTS' N owner d UST Is a Public agency.corrplate the follaMng:name ot Supsm aar of d"ion,section,or office which operates the UST TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTORR.1 IF INDDIAN a OF TANKS AT SITE E.P.A I.D.a(goolo") 3 FARM Q 4 PROCESSOR Q 6 OTHER OR TRUST LANDS 1 !1 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boablrgbW 0INDIVIDUAL 0 LOCAL-AGENCY STATE AGENCY u�J CORPORATION =PARTNERSHIP Q COUNTYAGENCY ED FEDERALdGENCY CITY NAME STATE ZIP CODE PHONE It WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box 0Micas Q INDIVIDUAL LOCAL-AGENCY STATE-AGENCY CORPORATION a PARTNERSHIP Q COUNTYAGENCY (]FEOERALAGENCY FE CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. TY(TK) HQ F4-14--]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓Eo�bMlfle>r (� I SELF-INSURED O 2 GUARANTEE O 3 INSURANCE O 4 SURETY BOND D S LETTEROFCREOIT D 6 EXEMPTION Q 99 OTHEfl VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or Itis ed. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: II. III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWCEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY W I �vCOUNTY# JURISDICTION a FACILITY a l' ^ LOCATION CODE -OPTIONAfjCENSUS OPT W (/ SUWISOR•OIS -CIPTDHAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(393) FORMM-RT r