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STATE OF CALIFORNIA 4mzz�'� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EAC CILITYISITE MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMA TLV ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE S�� I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS `` NEAREST CROSS STREET PARCEL#(OPTIONAL) � Q L CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE Pon ft CA `7533 I/ BOX TO INDICATE D CORPORATION O INDIVIDUAL =PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCYO STATE-AGENCY O FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR0 RESERVATION ✓ IF INDIAN #OF TANKS AT SITE E.P.A. L D.#(opti nal) 3 FARM � 4 PROCESSOR O 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 I WITH AREA 1111 II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREETADDRESS ✓boa 0indicale = INDIVIDUAL = LOCAL AGENCY STATE-AGENCY O CORPORATION = PARTNERSHIP =COUNTY-AGENCY Q 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 MAILING OR STREET ADDRESS ✓ box bindx;M D INDIVIDUAL O LOCAL-AGENCY O STATE AGENCY 0 CORPORATION PARTNERSHIP O COUNTY-AGENCY D FEDERALAGENCY 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 44 - O y V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bindicale [7) 1 SELF-INSURED 0 2 GUARANTEE E=j 3 INSURANCE E:1 4 SURETY BOND O 5 LETTEROFCREDIT O 6 EXEMPTION =99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box.1v II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.E] 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/YEAR LOCAL AGENCY USE ONLY C�ODUINITTY�# JURISDICTION# FACILTTV Ld/O-r LOCATION CODE-.OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL /-"?J-6 3z 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(5-91) FOR S