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• -6pJP � STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD skP UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EAC FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAORFACILITYN E_ /� •/,, NAMEOFOPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) � U A CITY NAME STATE ca ZIP CODE SITE PHONE#WITH AREA CODE BOX U TO INDCATE O CORPORATION NDIVIDUAL D PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY O FEOE L- AGENCY DISTRICTS TYPE OF BUSINESS O 1 GAS STAT N O 2 DISTRIBUTOR O ,/ IF INDIAN #OF TANI(S AT SITE E.P.A. I.D.#(optional) RESERVATION 1 O 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY)/ EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHON REA CODE DAYS: NAME(LAST,FIRST) iJ 5 a NI HTS: NAME(LAST,FIRST) - PHONE#WITH AREA COO NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CC, IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET'AD^DRESS L ✓ box b IMPute INDIVIDUAL = LOCAL-AGENCY Q STATE-AGENCY /a '15: e CORPORATION PARTNERSHIP = COUNTY AGENCY Q FEDERAL-AGENCY CITU N ME STATEZIP CODE P NE# TH AgEA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION eG � 7 MAILING OR STREET ADDRESS ✓ hox bliMlcate INDIVIDUAL V LOCAL-AGENCY 0 STATE-AGENCY COflPORATION O PARTNERSHIP 0 COUNTY-AGENCY (] FEDERAL-AGENCY CITYN�1E STATE ZIP CODE HONE#WITH AREA CODE lj a� 7 /' IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ F4]-4]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box b Indicate E-1 1 SELF INSURED Q 2 GUARANTEE 0 3INSURANCE E=15 LETTER OF CREDIT a SURETYBOND t� 6 EXEMPTION � 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: I.❑ it.z III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AN ORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION At FA LOCATION CODE -OPTIO L CEN US ACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL /a THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION FORM A(5-91) - FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATIOA ONLY. FOR0033A-5.