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• • STATEOFCALIFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Frs CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ITE ONE TEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OBAORF@CILITYyAM.(FK-E / �, NAMEOFOPERATOR S ADDRES/J\ NEAREST 9ROSS STREET PMCELII(OPrgNAW CITY NAM! V S ATE ZIP E SITE PHONE A WITH AREA CODE CA 7� TO INDICATE O CORPORATION INDIVIDUAL PARTNERSHIP D LOCAL-AGENCY 0 COUNTY-AGENCY' STATE-AGENCY' 0 FEDERALAGENCY' DISTRICTS' •If owner of UST Is a public agency,corroete the following:name of Supervisor of dNblon,section,or office whish operates the UST TYPE OF BUSINESS t GAS STATION ❑ 2 DISTRIBUTOR / ❑ RESERVATION A OF TANKS AT SITE E.P.A. I.D.A(apt/ma/) ❑ 3 FARM ❑ 4 PROCESSOR OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional [DAYS: NAME(LAST,FIRST) PHONE aWITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE IGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box IDmwa O INDIVIDUAL O LOCALAGENCY D STATE-AGENCY O CORPORATION O PARTNERSHIP D COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bindicate O INDIVIDUAL O LOCAL-AGENCY D STATE-AGENCY 0 CORPORATION O PARTNERSHIP O COUNTY AGENCY O FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE S WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 If questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED ✓ bm biMkab O t SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND 0 5 LETTEROFCREDIT 0 6 EXEMPTION Q 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. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 1.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY A JURISDICTION If FACILITY C 1213111 LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL SUPVISOR-DISTRICT CODE -G°TIONAL Lq LL 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(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS • il • FORom'MaT