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STATE OF CALIFORNIA r STATE WATER RESOURCES CONTROL BOARD 3� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �4 lion N`! COMPLETE THIS FORM FOR EACH FACILRY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTL SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OBAOR FACILITY NAMEI// NAMEOFOP RATOR W L/ C0,7_5#✓C770✓1 Ca pi I ADDRESS NEAREST CROSS STFt ET PARCEL#(OPTIONAL) z3zo S l 4 CITY NAME 40 STAcTE ZIP CODE SITE PHONE#WITH AREA CODE it a s, BOX I TO INDICATE E�wl `PORTDN 0 INDIVIDUAL Q PARTNERSHIP 0 LOCAL-AGENCY COUNTYAGENCY 0 STATE-AGENCY Q FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR / IF INDIAN #OF TANKS AT SITE E.P.A. I.D.4,IF ❑ 3 FARM ❑ 4 PROCESSOR je� 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) NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 9 WITH APPA QMP II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box b Indicate [—I INDIVIDUAL = LOCAL-AGENCY (]STATE-AGENCY I�CORPORATION O PARTNERSHIP Q COUNTY-AGENCY (] FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION Q 5 MAILING OR STREET ADDRESS ✓ box blMicale INDIVIDUAL = LOCAL-AGENCY Q STATE AGENCY O CORPORATION D PARTNERSHIP = COUNTY-AGENCY FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ F41-4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box blMicale F] 1 SELF-INSURED 0 2 GUARANTEE [-1 3 INSURANCE [�j d SURETY BOND I= 5 LETTER OF CREDIT 0 6 EXEMPTION O 93 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.poj�11.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAM E(PR INTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAV/VEAR LOCAL AGENCY USE ONLY COU�TNT]�Y�# JURISDICTION# FACILITY# /TW(Q Z3 I JT/ I � I— I�JL//JI_CL/JI_LL�i J LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SU`VIS�-QISS{i ICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION-- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ON FORM A(5-91) • /� F 0073A5 •