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• STATE OF CALIFORNIA • W.� STATE WATER RESOURCES CONTROL BOARD :d� �� UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A r _ , COMPLETE THIS FORM FOR EACH FACILITY/SITE ;a MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE D I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DS OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CI NAME STATE ZIP CODESITE PHONE#WITH AREA CODE CA ✓ BOX O CORPORATION O INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' 0 FEDERAL-AGENCY' TO INDICATE DISTRICTS I ovmerol UST is a public agency,complete the klbwing:reme of supervisorof 0lvispn,section oroKce which operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR = .1 IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optionaO RESERVATION O 3 FARM O 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional D Y : NAME LAST,FIRST) PHO] #WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 7�3-911 NIG TS: NAME LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE ^ II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS -�� ✓ box to mdcate 0 INDIVIDUAL O LOCAL-AGENCY ED STATE-AGENCY I_1 CORPORATION O PARTNERSHIP EJ COUNTY-AGENCY D FEDERAL-AGENCY CITY AME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) N MEOFOW ER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxtoidirate 0INDIVIDUAL LOCAL-AGENCY =1STATE-AGENCY (flzn t O CORPORATION O PARTNERSHIP COUNTY-AGENCY lM FEDERAL-AGENCY CI N-- AM PHONE#WITH AREA CODE - v IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F4]-4-]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box rointl ON 1 SELF-INSURED = 2 GUARANTEE O 3 INSURANCE E3 4 SURETYBOND 0 5 LErrEROFCREDIT =6 EXEMPTION L_j 7 STATEFUND O8STATE FUND&CHIEF FINANCIAL OFFICER LETTER Q9STATE FUND&CERTIFICATE OFDEPOSIT O10LOCAL GOVT.MECHANISM = 99OTHEfl 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.❑ II. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT TANKOWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAWYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE-OPTIONAL CENSUS TRACT-OPTIONAL SUPVISOR-DISTRICT 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 ONLY. OWNER MUST FILE THIS FORI&THE LOCAL AGENCY IMPLEMENTING THE UNDERGRCIVRAGE TANK REGULATIONS FORMA(6-95)