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1f °o STATE OF CALIFORNIA ''� STATE WATER RESOURCES CONTROL BOARD ?,,,�, m UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A > - COMPLETE THIS FORM FOR EACH FACILITY/SITE in 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) yya� CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CoQ CA Iz::?XLdfZ ✓BOX O CORPORATION O INDIVIDUAL 0 PARTNERSHIP [:1 LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' O FEDERAL-AGENCY' TO INDICATE DISTRICTS Now rof UST'sa Wbkagency,mmq athefolbwng rams d swenisorol diieion,sedbn or office w O operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION 2 DISTRIBUTOR ❑ ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 'v _ Lt S~sG NIGHTS: NAME(LAST,FIRST r PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION /GN- WSho MAILING OR STREET ADORE S ✓ Doo to morale INDIVIDUAL Q LOCAL-AGENCY O STATEAGENGY Z, 7 CORPORATION O PARTNERSHIP O COUNTYAGENCY FEDERAL-AGENCY CITY NAME ST� ZIP CODE PHONE#WITH AREA CODE ao III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWN�}R CARE OF ADDRESS INFORMATION ESI C/ MAILING O(R�STREET AD RESS ✓ box to m#sele D INDIVIDUAL Q LOCAL-AGENCY D STATE-AGENCY zf d ,W l=CORPORATION PARTNERSHIP 0 COUNTY-AGENCY E�] FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE G,,n C4 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 METHOD(S) USED ✓baa biMiCele I SELF-INSURED =1 2 GUARANTEE I= 3 INSURANCE 0 4 SURETYSOND I= 5 LETTEROFCREDIT =6 EXEMPTIONI�T STATE FUND O8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND&CERTIFICATE OF DEPOSIT O10LOCAL GOVT.MECHANISM O 9BOTHER 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.❑ II.❑ 111.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# G�r LOCATION CODE -OPTIONAL CENS'ULS.TRACV OPTIONAL SUPVISOfl-DISTRICT CODE -OPTIONAL 77 (� V THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(6-95)