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STATE OF CALIFORNIA . rc'� STATE WATER RESOURCES CONTROL BOARD z ° UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� "° COMPLETE THIS FORM FOR EACH FACILITY/SITE wo MARK ONLY F-] 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ < AMENDED PERMIT 8 TEMPORARY SITE CLOSURE 5.3 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CIN NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CA ✓BOX Q CORPORATION O INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' Q FEDERAL-AGENCY' TO INDICATE DISTRICTS II owner of UST is a public agency,complete the following:roma of supervisor of division,section or office which operates the UST TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓R NDAKS AT SITE E.P.A I.D.#(optional) ❑ ❑ ❑ REBIFINDIAN #OFT 0 3 FARM Q 4 PROCESSOR = 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COIIAPLFTFD) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bcr to rGtTa O INDIVIDUAL Q LOCAL-AGENCY 0 STATE AGENCY O CORPORATION O 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 ✓ Covto ialcke [:D INDIVIDUAL D LOCAL-AGENCY O STATE AGENCY O CORPORATION O PARTNERSHIP O COUNTY-AGENCY D FEDERAL-AGENCY CITY NAME STATEZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ F4_[4_-1- V. 4- -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓boa to ind'rate 1 SELF-INSURED L::] 2 GUARANTEE =3 INSURANCE =4 SURETY BOND 0 5 LETTEROFCREDR [:716 EXEMPTION I]T STATEFUND Q 0 STATE RIND&CHIEF FINANCIAL OFFICER LETTER O 9 STATE FUND&CERTIFICATE OF DEPOSIT D 10 LOCAL GOVT.MECHANISM O 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.❑ if.❑ III.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 MONTHiDAV/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# ti:L I I�'• :I:'-('#- Z LOCATION CODE -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. OWNER MUST FILE THIS F ITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGQSD STORAGE TANK REGULATIONS FORM A(6-95)