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• 0 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD u�� m°o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A .A _ COMPLETE THIS FORM FOR EACH FACILITY/SITE le MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) V CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE mon CA 4 5p6W 0 ✓ BOXINCORPORATION [=1 INDIVIDUAL E:1 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCY' = FEDERAL-AGENCY' TO INDICATE DISTRICTS Hamer of UST's a public agency,mmplete the following:came of swermorof d"lon.WiDn oroffce whdi o"Wes the UST TYPE OF BUSINESS ❑ I GAS STATION O 2 DISTRIBUTOR ❑ pEV IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(opfimal) Q 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAVE(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIME(LAST,FIRST) PHONE#WITH AREA CODE - NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE GHTS: NA II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAMECARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxlo odeMe O INDIVIDUAL 0 LOCAL-AGENCY I]STATE AGENCY 2 11,D w. L,O b= [71 CORPORATION D PARTNERSHIP [:D COUNTY-AGENCY [::] FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITHAREACODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION ILI AA_ MAILING OR STREET ADDRESS ✓ boxtomdmle Q INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY CORPORATION = PARTNERSHIP O COUNTY-AGENCY D FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE N WITH AgFJ CODE -+- C4v IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F474- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to ind#ale = I SELF-INSURED = 2 GUARANTEE (=3 INSURANCE =4 SURETY BOND =5 LETEROFCREDB =6 EXEMPTION O T STATE FUND =B STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE RIND&CERTIFICATE OF DEPOSIT I= 10 LOCAL GOVT.MECHANISM O99 OTHFR 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 NOTIFICATION$AND BILLING: I.❑ II. IN.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TA NK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# X:: LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SL!jq-DISTRICT CODE -OPTIONAL -)- 3 0 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(695) OWNER MUST FILE THIS FOR0-H THE LOCAL AGENCY IMPLEMENTING THE UNDERGRqe STORAGE TANK REGULATIONS