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` STATE OF CALIFORNIA • STATE WATER RESOURCES CONTROL BOARD �wt`t, •,6 o M1 o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A m COMPLETE THIS FORM FOR EACH FACILITY/SITE `ie /I MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED.SIT v 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 PARCELtl(OPTIONAL) 5 CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CA ✓BOX CORPORATION ❑ INDIVIDUAL 0 PARTNERSHIP ❑LOCAL-AGENCY [D COUNTY-AGENCY' ❑ STATE-AGENCY' ❑ FEDERAL-AGENCY' TO INDICATE DISTRICTS 8 owner of UST's a .Arc agmy.comlele the lollowmg:ram,,f supeNsor rvisbn,WIDn orae which opemles the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRI&OR ❑ RESEAVADI] #OF TAN SITE E.P.A I.D.#(optional) ❑ 3 FARM E::] 4 PROCE9JR Q 5 OTHER OR TRUST LANDS3 EMERGENCY CONTACT PERSON (PRIMIY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#VH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 71 NIGHTS: NAME(LAST,FIRST) PHONE p VH AREA EA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST=-00lI4PLFTFD) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxb elm ❑ INONIDUAL ❑LOCAL-AGENCY ❑ STATE- AGENCY ❑CORPORATION ❑PARTNERSHIP ❑ COUNTY-AGENCY ❑ FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE CNPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxtointlioate ❑ INDIVIDUAL ❑ LOCAL-AGENCY ❑ STATE-AGENCY ❑CORPORATION PARTNERSHIP ❑ COUNTY-AGENCY ❑ FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILIT`t(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to iodi=9 ❑ 1 SELF-INSURED ❑2 GUARANTEE ❑3 URANCE ❑4 SURETY BOND = 5 LETTEROFCREDrr ❑6 EXEMPTION ❑T STATE FUND ❑8 STATE FUND B CHIEF FINANCIAL OFFICER LETTER ]9 STATE RIND B CERTIFICATE OF DEPOSIT ❑ 10 LOCAL GOVT.MECHANISM ❑ 9907HER 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 USD FOR LEGAL NOTIFICATIONS AND BILLING: 1.[::] II.[::]7 III.O THIS FORM HAS BEEN COMPLETED UNDER PENALrOF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTEDB SIG NATURE) TANK OWNER'S TITLE DATE MONTWDAYTYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# I= I I 1;;I&k 7_342fj:� FLOCATIONE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -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. FORM A(6-95) OWNER MUST FILE THIS FOWITH THE LOCAL AGENCY IMPLEMENTING THE UNDER((WD STORAGE TANK REGULATIONS r