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STATE OFCALIFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION a FORM A COMPLETE THIS FORM FOR EA CILITYISITE 1 NEW PERMIT 5 CHANGE OF INFORMATION Ej 7 Y� MARK ONLY 7 RENEWAL PERMIT PERMANENTLY CLOSED ONE REM 2 INTERIM PERMIT O d AMENDED PERMIT a TEMPORARY SITE CLOSURE _ I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBZ/R FACILITY MME — N ME OF OPERATOR RES ADONE STCROSS TR ET PARCELCOPTONAL) �A VI� CITY NAME ,{ STATECA ZAP COgG,� SITE PHONE s WITH AflEA CQpE_�— / TOINDICATE IQ CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q cmNry,AGEgCy. Q STATE-AGENCY' FFDERALAGENCY DISTRICTS' Q • 'N oener d UST Ia a public agency,001nPlMe the following:name of Supercar of division.section.a pain whIch postal"the UST TYPE OF BUSINESS Q I GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN a OF TANK TSITE E.P.A I.D.a(gdAnaq Q 3 FARM Q A PROCESSOR Q RESERVATION Q 5 OTHER OR TRUST LANDS I I 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(VST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(VST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME - CARE OF ADOflESS INFORMATION MAILING OR STREET ADDRESS I f ✓ ....EorbiM. Q INDIVIDUAL Q LOCAL AGENCY V Q STATE AGENCY Q CITY NAME CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL AGENCY STATE ZIP CODE PHONE a WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ pox* Q INDIVIDUAL Q LOCAL.AGENCy STATEAGENCY CITY NAME Q CORPORATION Q PARTNERSHIP Q COUNTYAGENCy Q FEDERALAGENCY STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(9 16)322-9669 if questions arise. TY(TK) HQ 1 7� f1s. V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓ Xotmicm t SELFINSURED O 2 GUARANTEE Q T INSURANCE D s LETrEROFCREDIT Q B E%EMPTION 9B OTHER O A SURETYBOND Q A. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is checked. CHECK ONE BOx INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. 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) OWNER'S TITLE WTE MONTWDAY/YEAR LOCAL AGENCY USE ONLY / 7 r COUNTY a JURISDICTION x FACIrtY's - I`��J�L71f7`''FIPT 1*7 I LOCATION -OPTIONAL CENSUS TRACTa - SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE BFORMATION ONLY. FORM A(31193) OWNER MUST FILE THIS FORM Y'_."THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND )RAGE TANK REGULAT1r " AA ,