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` t50uP f STATE OFCALIFORNAA STATE WATER RESOURCES CONTROL BOARD 3f. UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILRYISITE MARK ONLY Q 1 NEW PERMIT 0 3 RENEWAL PERMIT E?r5 CHANGE OF INFORMATION 7 PERMANENT CLOSED SRE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATIONBADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR v ADDRESS _ NEAREST CROSS STREET PMCEL#(OPONAL) C CITY NAME STATE ZIP CODE SITE PHONE IS WITH AREA CODE CA TO INDICATE O CORPORATION INDIVIDUAL Q PARTNERSHIP LOCAL-AGENCY 0 COUNTYAGENCY Q STATE-AGENCY 0 FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS I GAS STATION O 2 DISTRIBUTOR 0 RESERVATION IF INDIAN IS OF TANKS AT SITE E.P.A. I.D.#Inpiranali O 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) I PHONE 4 WITH AREA COOP II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bowbindle#e E::] INDIVIDUAL LOCAL-AGENCY STATE-AGENCY D CORPORATION = PARTNERSHIP COUNTYAGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANKOWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS- ✓ bon 0indicate O INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY CORPORATION Q PARTNERSHIP Q COUNTYAGENCY I= FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE IS WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 -LVL V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ bon n,indicate I SELF-INSURED 0 2 GUARANTEE [_1 3 INSURANCE 0 4 SURETY BOND 5 LETTER OF CREDIT =6 EXEMPTION El 99 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: 1.O II.= IN. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED a SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 3 : 5 CCL� � LOCATION CODE -OPTIONAL (CENSUS TRACTS -OPTIONAL SUPVISOR-DISTRIIT CODE -OPTION L-3 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SrTE INFORMATION ONLY, ({III FORM Ape 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS