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• 'y60U• � STATE OF CALIFORWA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE J_ °•"'°""�- MARK ONLY O I NEW PERMIT D 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY C ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT a TEMPORARY SITE CLOSULORE 3 I. FACILITYISITE INFORMATION ADDRESS-(MUST BE COMPLETED) DBA OR FACILITVN E NAMEOFOPERATOR ADDRESS NEAREST CRO STREET PARCEL#(OPfIONAL) [7j(/lAll P CITY NAME STATE ZIP SITE PHONE IF WITH AREA CODE C K CA }-- TOINDICRTE O CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY 0 GOUNTYAGENCY' O STATE-AGENCY' O FEDERAL DISTRICTS' N owner of UST is a public agency,mn1plete the following:name of Supervisor of 0"lon,section,or o5im which operates the UST TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.#(oPfwval) 0 RESERVATION 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonal DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE is WITH AREA CODE PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED CARE OF ADDRESS INFORMATION LNAMER STREET ADDRESS ✓ box bind'bate INDIVIDUAL LOCALAGENCY STATE-AGENCY O CORPORA ON 1 PARTNERSHIP COUMYAGENCV FEDERA4PGENCV E STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) ;NAME OF OWNER CAREOFADDRESS INFORMATION ILING OR STREET ADDRESS ✓ box biMicate O INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY 0 CORPORATION O PARTNERSHIP COUNTY C_I FEDEMLAGENCV CITY NAME STATE ZIP CODE PHONE#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 BE COMPLETED)—IDENTIFY THE METHODS) USED ✓ bo[bintlkate Q I SELF INSURED 0 2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND 5 LETTER OF CREDIT 0 6 EXEMPTION E:1 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.E] I.D III.O 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 r COUNTY# JURISDICTION# FACILITY# LOCATIONCODE -OPT CENSUS TRACT -OPTIONAL SUPVISOR-DISTr^RICT EE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLENENTINGTHE UNDERGROUND STORAGE TANK REGULATIONB Faaro>Ant FORM A(393)