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STATE OF CALIFORNIA �•- STATE WATER RESOURCES CONTROL BOARD -�� •,•• UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY Ej 1 NEW PERMIT Q 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CL ONE REM O 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �[ 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) a DBAOR fA ILITY NAM L> g NAME OF OPEGUT R na C IC �i ADDRESS NEARE TCROSS SLTRE RCFl PAa(pPrONAU CITY NAMEA se` STATE ZIP SITE PHONE a WITH AREA CODE CA $11 Box ZD TO INDICATE 0 CORPORATION Q INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY O COUNTYIWENCY' ID STATE-AGENCY- O FEDERALAGENCY' N owner of UST Is a Public agencY,mnplele the Tohov in :none of S DISTRICTS' a 0 upervkor of tlivkbn,eettbn, rffi hkh gNNates the UST TYPE OF BUSINESS O ! GAS STATION Q 2 DISTflIBUTOR ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a(opfbnalj REV Q 3 FARM Q 4 PROCESSOR OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optimal GAYS: NAME(LAST,FIRST) PHONE It 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 S WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION I'» MAILING OR STREET ADDRESS ✓box blMkale 0 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY O CORPORATION O PARTNERSHIP COUNTYAGENCY =FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAJUNG OR STREET ADDRESS ✓boa bkdkma O INDIVIDUAL (] LOCAL-AGENCY Q STATE-AGENCY O CORPORATION ] PARTNERSHIP E=1 COUNT -AGENCY = FEDEPALAGENCY CRY NAME 9TATE ZIP CODE PHONE a WITH AREA CODE N.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if quesBons arise. TY(TK) HQ 4 4- - y� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)-IDENTIFY THE METHOD(S) USED .1 yNl x, ,y, Q 1 SELF-INSURED E—)2 GUARANTEE 0 3 INSURANCE O 4 SUREN BDND D 5 IETTEROFCREDIT =6 ExEmFnoN = W 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: I. Z.O III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTHDAYIYEAR LOCAL AGENCY USE ONLY COUNTY• JURISDICTION FACILITY# CIl6� 15 7 1 LOCATION CODE .OPTIONAL CENSUS TRACTII -OPTIONAL SUPVISOR-DISTRICT CODE - THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE IIFORWT"ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS\'/h FORM A(3'93)