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^xuoon e. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A Cit ISO1�N� COMPLETE THIS FORM FOR EACH FACILRY/SITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYLOS ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTK)NALt CHYNAME STATE ZIP CODE SITE PHONE WITH AREA CODE Ca A ✓ Box TO INDICATE CORPORATION Q INDIVIDUAL D PARTNERSHIP D LOCAL-AGENCY O COUNTY-AGENCY D STATE-AGENCY O FEDERAL AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) ❑ RESERVATION 0 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CO CT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST.FI RST) PHONE AREA CODE DAYS: NAME(LAST,FIRST) PHONE I WITH AREA CODP NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) EHQbIE#WITH AREA CODE II. PROPERTY OWNER INFORMATI MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boa birdkale INDIVIDUAL 0 LOCAL-AGENCY [�] STATE AGENCY _ Q CORPORATION Q PARTNERSHIP 0 COUNTY AGENCY E-] FEDERAL AGENCY CIN NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST B COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILINGOR STREET ADDRESS• ✓ Dox blMical6 0 INDIVIDUAL 0 LOCAL-AGENCY (]STATE-AGENCY O CORPORATION =1 PARTNERSHIP Q COUNTY-AGENCY E] FEDERAL-AGENCY CITY NAME' - STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE A COUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HO �44]-[ V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MU T BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box NinOical# L� I SELF INSURED 0 2 GUARANTEE L_j H INSURANCE Q 4 Sl1RETV BOND 5 LETTER OF CflEDR O 6 EXEMPTION E-1 59 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal no'ication 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 LEGA 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 APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/VEAR LOCAL AGENCY USE ONLY1�d - COUNTY# JURISDICTION# FACILITY# LOGATIONCODE -OPTION I CENSUS TRACT# -OPTIONAL SUPVISOR-DIST TCODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION FORM A(12-e1) FILE THIS FORM WITH THELOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS