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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A v o C°x,f OXM,n COMPLETE THIS FORM FOREACHFACILRYISITE MARK ONLY F__] I NEW PERMIT ❑ 3 RENEWAL PERMIT lyl 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT JI�J5 a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OBA OR FACILI A ftrVSEd NAME OF OPERATOR ADDRESS O NEAREST CROSS STREET PARCEL#(OPTIONALI q"51 6 aALA CITY NAME STATE ZIP ODE SITE PHON WITH AREA CODE CA rj TO INDCATE CORPORATION O INDIVIDUAL I� PARTNERSHIP L LOCA-AGENCY D COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION ❑ 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS �. EMERGENCY CONTA ERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 9 WITH AREA rOnP NIGHTS: NAME(LAST,FIRST) PNQNE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODF II. PROPERTY OWNER INFORMATION• MUS E COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box bindicate D INDIVIDUAL IED LOCAL-AGENCY Q STATE-AGENCY O CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY O 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 to ndkate E:] INDIVIDUAL O LOCAL AGENCY O STATE-AGENCY ORPORATION 0 PARTNERSHIP Q COUNTY AGENCY O FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call 16)323-9555 if questions arise. TY(TK) HQ 44 -L 12LI1� V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box b indicate I SELF-INSURED L_j 2 GUARANTEE O 3 INSURANCE 0 4 SURETY BIND 5 LETTEROFCREDIT I=6 EXEMPTION 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.D II.[—] III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY jEgAadr COUNTY# JURISDICTION# FACILITY# LOCATIONCODE -OPTIONAL CENSUS TRACT# -OP SUPVISOR-DISTRICTCODE -OPTIONAL y On THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- ORM B,UNLE S THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(5-97) � FOR0033A-5