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c STATE OF CALIFORNIA ti STATE WATER RESOURCES CONTROL BOARD W�� a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , os COMPLETE THIS FORM FOR EACH FACILITYISITE °•�,.a.•'- MARK ONLY O 1 NEW PERMIT 0 3 RENEWAL PERMIT Q S CHANGE OF INFORMATION rx 7 PERMANENTLY ONE REM F-12 INTERIM PERMIT Q d AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE �j I. FACILITY/SITE INFORMATION 14 ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR kyl ADDRESS NEAREST CROSS STREET PMCEL#IOPTONAL) CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CA a TO INDICATE E_j CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY O COUNTY AGENCY' O STATE-AGENCY' Q FEDERAL-AGENCY' DISTRICTS' N owner d UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS O t GAS STATION 2 DISTRIBUTOR = RE/ IF INDIAN SERVATION 10 OF TANKS AT SITE E.P.A, I.D.s(cpfAeMe 0 3 FARM a PROCESSOR 5 OTHER ORTRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE Is WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME _ CAREOF ADDRESS INFORMATION MAILING OR ST REST ADDRES - ✓bDsb 0 INDIVIDUAL O LOCAL-AGENCY I]STATE-AGENCY CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY N�.GE f TATE ZIP E /0 PHONE#WITH AREA CODE G 111. TANK OWNER INFORMATION (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓butim"a INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY O CORPORATION D PARTNERSHIP D COUNTYAGENCY 0 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 ✓bM t Intense O I SELF INSURED 0 2 GUARANTEE O 3 INSURANCE O I SURETY BOND D s LETTEROFCREDIT L-1 I EXEMPTION O Ig 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.O 11.X III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED A SIGNED) OWNER'S TITLE DATE MONTHIDAVNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION III FA�� CIILITY#X�0y�0 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT OPTIONAL THIS 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 13A13)