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• • STATE OF CALIFORNIA `i STATE WATER RESOURCES CONTROL BOARD s'f'' '� UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A " ` a Y.I , Z oa Wper°n COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION EV 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DDA OR AGILITY NAMY NAME OF OPERATOR C. a44a k., ADOR 5Al A01 NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAMESTATE CZIP Cy./pE __ SITE PHONE#WITH AREA CODE ABOX TOINSGC TE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY QCC`OUNry.AAAGENNCY Q STATE AGENCY DISTRICTS Q FEDERAL TYPE OF BUSINESS ❑ T GAS STATION ❑ 2 DISTRIBUTOR I Q ✓ IF INDIAN #OF K T SITE E.P.A. I.D.#(apt,mae RESERVATION Q 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUSTLANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST( PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONF#WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boa blrkkale Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q 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 ✓ boabintlkaw Q INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 14 T41- 2 Z V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓bw biMkale Q 1 SELF-INSURED Q GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q 5 LETrER OF CREDIT 6IXEMPT ON Q 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: I.❑ IL❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PR INTED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# ® FTTI LOCATION CODE -OPTION CENSUS TRACT-Q TIOA{4L.� SUPVISO -DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(7)OR MORE PERMIT APPLICATION• FORM 91) B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5 91)