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• • �soue � STATE OFCAUFORMA , STATE WATER RESOURCES CONTROL BOARD i '4 UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A .offi 0 -� COMPLETE THIS FORM FOR EACH FACILITY/SITE •°.�„e,,,,,�' MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENT ONE REM O 2 INTERIM PERMIT Q A AMENDED PERMIT g TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION III ADDRESS-(MUST BE COMPLETED) OBAOR FACILITY NAME ADD UES OF OPERATOR ADD E S `J NEAREST CROSS STREET PMCEU(OPrDNAq CI N E ST CA D/ SITE PHONE a WITH AREA CODE I/Box TOINDICATE 0 CORPORATION O INDIVIDUAL (]PARTNERSHIP 0 LOCAL T•AGSENCY 0 COUNTYAGENCY' 0 STATE-AGENCY' 0 FEDERAL-AGENCY' I owner d UST Is a pubic Agency,mrrplde IM IOIbMrle:nalM d eN SUpAtd d tlh4bsection.section.n, n,or dike which operates the UST TYPE OF BUSINESS Q I GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN 1000 TAMP AT SITE E.P.A. I.D.0(gNimap Q 3 FARM Q A PROCESSOR 0 5 OTHER a RESERVATION 0'�”" OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PwmH AREACCDE DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE DI NIGHTS: 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 STREETADDRES9 ✓ box blMbaM E::] INDIVIDUAL =LOCAL-AGENCY 0STATE-AGENCY O CORPORATION O PARTNERSHIP 0 COUNrYAGENCY 0 FEDERAL-AGENCYCITU 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 ✓ box bindict, INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY 0 CORPORATION 0 PARTNERSHIP ED COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HO 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box blbkaM D I SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE A SURETY BOND 5 LETrER OF CREDIT 0 6 EXEMPTION 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. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULDBE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.Ej 11.[::] 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 A SIGNED) OWNER'S TITLE DATE MONTWDAVNEAR LOCAL AGENCY USE ONLY ..> COUNTY p JURISDICTION It FACILITY• m LOCATION CODE OPTIONAL CENSUSTRACTe -(OPTIONAL SUPVISOR-DISTAICTDOOF•'OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS S A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(3N3) FOR00.15A117 .. ..IC ; .