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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3 dam, m a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EACH FACILITY/SITEfd a MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED. ONE ITEM ❑ 2 INTERIM PERMIT E::] 4 AMENDED PERMIT fi TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME r NAME OF OPERATOR ADDRESS NEA111ST CROSS STREET PARCEL If(OPTIONAL) CITY NAME STATE ZIP C DE SITE PHONE If WITH AREA CODE CA ✓BOX O CORPORATION [:1 INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AG V- 0 FEDERAL-AGENCY' TO INDICATE DISTRICTS Hamerol UST'a Pablka9erq,mmp'tethefolbwnT..nameofmpereimroldivision,seQanor oft which operates the UST TYPE OF BUSINESS a 1 GAS STATION Q 2 DISTRIBUTOR = RESEIRVATION 8 OF TANKS AT SITE E.P.A. I.D.M(optional) 3 FARM ❑ 4 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE I WITH AREA COFF=j DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(VAST,FIRST) PHONE H WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING ORSTREETADD ESS ✓ tx:xten=a O INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY O CORPORATION = PARTNERSHIP = COUNTY-AGENCY D FEDERAL-AGENCY CITY IS s STATE ZIP CODE PHONE K WITH AREA CODE C 41 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ Cox to ndrate = INDWIDUAL OLOCAL-AGENCY STATE-AGENCY Q CORPORATION O PARTNERSHIP Q COUNT'-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED .1 box to irdrale O 1 SELF-INSURED = 2 GUARANTEE O 3 INSURANCE =4 SURETY BOND =5 LET TER OF CREDIT =6 EXEMPTION IJ T STATE FUND Q 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM 0 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.❑ 11.❑ Ill.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE I DATE MONTH(DAYYEAR LOCAL AGENCY USE ONLY oZ - 4' � COUNTY P JURISDICTION N FACILITY X ® [� b LOCATION CODE -OPTIONAL CENSUSTRACT_#�•OPT/ONAL SUPVISOR-DISTRICT CODE •OPTIONAL 7 THIS FORM MUS 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 FOR THE A�AGENCY IMPLEMENTING THE UNDERGRO�TORAGE TANK REGULATIONS � 10��•�� FORM A(6-95) C 8 IMPL P G Y^