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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACHFACILITYISITE MARK ONLY O t NEW PERMIT 0 3 RENEWAL PERMIT s CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE REM 0 2 INTERIM PERMIT Q 4 AMENDED PERMITTEMPORARY SITE CLOSURE ` I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR - I IADDRE NEARESTC E �( CITY STATE ZIP CODE SITE PHONE s WITH AREA CODE CA 416 6 TO DICATE O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP O DISTFUASENCY 0&I Y.AGENCY' 0 STATE-AGENCY FEDERAL-AGENCY' / D STPoCTS' '11 owner of UST Is a public agency,corrplele the following:name of Supervisor of division,sectkn,or otic which operain the UST TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTORQ ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a(opOmag RESERVATION 3 FARM PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILI OR T E ✓ INDI A L A CrSTATE-AGENCY CORPORATION PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY CITY NAM V STATE ZIP CODE PHONE a WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET'ADDRESS ✓ box budade 0 INDIVIDUAL 0 LOCAL AGENCY 0 STATE-AGENCY D CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL.AGENCY CITY NAME - STATE ZIP CODE PHONE%WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ bar b intlka�e D I SELF-INSURED 0 2 GUARANTEE = 3 INSURANCE O i SURETY BOND 5 LETTER OF CREDIT 0 6 EXEMPTION L 1 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.❑ I HE THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEANDc6RRECT OWNER'S NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY a JURISDICTION• FACILITY M m LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL 9UPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF STIE INFORMATION OM OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A WN) • 3 -97