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.STATE OF CALIFORNIA �swe ee STATE WATER RESOURCES CONTROL BOARD o .o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILrTYISITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS` ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBAORFACILITV NAME NAME OF OPERATOR —f 1 ADDRESS INEAREST CROSS STREET PABCELaIOPTx)NAM CI NAME STATE ZIP CODE - J\ / SITE PHONE WITH AREA CODE C CA TO INBOX DICATE (=CORPORATION I= INDIVIDUAL = PARTNERSHIP = LOCAL AGENCY = COUNTY-AGENCY DISTRICTS STATE-AGENCY = FEDERALAGENCY TYPE OF BUSINESS O I GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN a OF TANKS AT SITE E. 3 FARM 4 PROCESSOR 5 OTHER O RESERVATION ❑ ❑ OR TRUST LANDS EMERGENCY CO ACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) If. PROPERTY OWNER INFORMATI MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION x MAILING OR STREET ADDRESS ✓ botbintlbale = INDIVIDUAL (] LOCALAGENCY = STATE-AGENCY =CORPORATION I= PARTNERSHIP = COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE 11 III. TANK OWNER INFORMATION-(MUSTBkCOMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box biMbate I= INDIVIDUAL = LOCAL.AGENCY =STATEAGENCY CORPORATION = PARTNERSHIP COUNrYAGENCY I= FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE x WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE A COUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ L4_ 47-[� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MU T BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box to indicate F. 99 OTHER I SELF INSURED =2 GUARANTEE 3 INSURANCE =5 LETTER OF CREDIT =6 EXEMPTION =4 SURETY BOND = , VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal no'fication 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.Ej IL D In.❑ 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 MONTHIDAYNEAR LOCAL AGENCY USE ONLY d COUNTY# JURISDICTION# FACILITY# 11, E _ «l _ LOCATION COLE OPTIONAL CENSUS TRACT p -- - -_- -- OPTIONAL SUPVISOR-DISTR 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 ONLY. FORM A(12 911 FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDEPAROUND STORAGE TANK REGULATIONS FOR0033A.A6