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STATE OF CALIFORNIA ,S ' STATE WATER RESOURCES CONTROL BOARD + #0 UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM A w� � o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT /Z5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR 3r, l Av -L-fl�� ADORES ! NEAREST CROSS STREET - PARCEL#(OPTIONAL) CITU NAME ✓ BOX STATE ZIP CODE SITE PHONE M WITH AREA CODE TO INDICATE 0 CORPORATION O INDIVIDUAL 17:1 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' D STATE-AGENCY' O FEDERAL AGENCY' I/owner of UST Is a public agency,complete the following:name W Supervisorr of division,section,or office which operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) �.,,� RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR 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) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME ILAST,FIRST) PHONE x WITH AREACODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILINGOR STREETADDRESS ✓boxbindbale O INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY CORPORATION (] PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILINOORSTREETADDRESS ✓ box binsala E-1 INDIVIDUAL LOCAL-AGENCY D STATE-AGENCY [ CORPORATION O PARTNERSHIP Q COUNTY AGENCY FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 4 IV.BOARD OF EQUALIZATION UST ST AG EE ACCOUNT NUMBER Call(916)322-9669 if questions arise. TY(TK) HQ 7441- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box b Indicate O 1 SELF-INSURED E__1 2 GUARANTEE Q 3 INSURANCE O 4 SURETY BOND E__1 5 LETrEROFCREDIT 0 6 EXEMPTION O N 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.❑ II.❑ III THIS FORM HAS BaEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED B SIGNED) OWNER'S TITLE DATE MONTHIDAYIYFAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# Hl LOCATION CODE -OPTIONAL CENSUS TRACTa -OPTIONAL 3UPVISOR-DISTRICT CODE -l7PTTOAUL I ED 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(393) • • FpiDW1AA]