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peW° e STATEOFCALIFORNUA STATE WATER RESOURCES CONTROL BOARD ' UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACHFACILITYISITE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION T PERMA _ TLY CL I ONE REM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ a TEMPORARY SITE CLOSUR I. FACILrrY/SITE INFORMATION 8 ADDRESS-(MUST BE COMPLETED) DBA OR FACILITYZ/ E NAME OF OPERATOR ADDRESS NEAREST ROSS STREET PARCEL#(OPTIONAL) CITY NAME j SATE ZIP DE SITE PHONEi WITH AREA CODE CA Box LocAL-AG TO INDICATE D CORPORATION INDIVIDUAL =PARTNERSHIP Q DISTRIC SENCY O COUNIV,IGENCY' 0 STATE AGENCY' O fEOEMLdGENCY• 'I owner d UST Is a public agency,ccntPlete the followng:name of SupeNlsor d dimicn,section.m office which operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOfl / IF INDIAN/ I❑ RESERVATION i OF TANKS AT SITE E.P.A. I.D.i(opflonal) ❑ 3 FARM ❑ a PROCESSOR OTHER ORTRUSTLANDS EMERGENCY CONTACT PERSON (PRIMARY) - EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST( PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE i WITH AREA CODE 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ Wo 0 micale INDIVIDUAL LOCAL-AGENCY C STATE AGENCY 0 CORPORATION O PARTNERSHIP O COUNTYAGENCY = FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boawma C—] INDIVIDUAL 0 LOCAL AGENCY O STATE AGENCY a CORPORATION Q PARTNERSHIP O COUNTY AGENCY O FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ boa b4bkate O 1 SELF-INSURED D 2 GUARANTEE O 3 INSURANCE O s SURETY BONO O 5 LETTER OF CREDIT O 6 EXEMPTION C W 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: 1.❑ II.❑ IN.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED a SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY a JURISDICTION u FACILITY It 7 �I 3 l LOCATION CODE -OPTIONAL CENSUS TRACT i -OPTIONAL 9UPVISOR-DISTRICT CODE -Q^TANK THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE ITFOAMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU FORAGE TANK REGULATIONS FORM A(3N3) • TQU¢13A{iT