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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD' lb UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A &, 1�� COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT E—] 5 CHANGE OF INFORMATION ] PERMANENTLY CLOSED S ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSUR - I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) VVV DBAORFACILITYNAME NAMEOF OPERATOR A ID ADDRESS`SIL 6 NEAREST GROSS ETR EF` T PARCEL 0(OPTIONAL) E , i /lvGlsi�,uK/ CITU NAME' STATE ZIP CODE SITEPHONE#WITHAREACODE CA ✓ Box y� TO INDICATE YI CORPORATION E-1INDIVIDUAL = PARTNERSHIP D LOCAL-AGENCY Q COUNTY-AGENCYf� STATE-AGENCY E::] FEDERAL-AGENCY 7'� DISTRICTS TYPE OF BUSINESS ( GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#Notional) RESERVATION40 ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS MAO EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) HONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE I WITH"PA C01117 NIGHTS: NAME(LAST,FIRST) PH E#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA CODI II. PROPERTY OWNER INFORMATION• MUS BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓boabkW'Cab [—I INDIVIDUAL 11 LOCAL-AGENCY E] STATE-AGENCY \— O CORPORATION O PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPL ED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boa blMkale INDIVIDUAL LOCAL-AGENCY (] STATE-AGENCY Q CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERALAGEWY CITY NAME - STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bktlkMe /f ) n = 1 SELF INSURED 0 2 GUARANTEE 0 5 INSURANCE 4 SUR rV 19 E-15 LETTER OF CREDIT 6 EXEMPTION 99 OTHER ETY BOND 771 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: 1.X II.❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAVNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 311 OCATIONCODE OPTIONAL ICENSUS TRACT# .OPTQNAL SUPVISOR-DISTRICT CODE -OPTIONAL © 1 3 ?6 THIS FORM MUST BE ACCOMPANIED BY AT LEAST())OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFO TION ONLY. FORM A02-ell FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORD033A96