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• 0 STATE OF CALIFORNIA e n,0 ( STATE WATER RESOURCES CONTROL BOARD iy - UNDERGROUND STORAGE TANK PERMIT APP TION - FORM A �� v COMPLETE THIS FORM fOR EAC CILITYISITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAORFACILITY NA7� - p NAMEOFOPERATOR h �O ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITU NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE ✓ BOX TO INDICATE O CORPORATION O INDIVIDUAL I=PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY O STATE-AGENCY FEDERALAGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION -__j2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(.P#m#I) RESERVATION ❑ 3 FARM E=] 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) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bindlcWe D INDIVIDUAL E::] LOCAL AGENCY E] STATE-AGENCY O CORPORATION O PARTNERSHIP COUNTY-AGENCY = 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 ✓box b lndbale INDIVIDUAL LOCAL-AGENCY D STATE-AGENCY D CORPORATION D PARTNERSHIP El COUNTY-AGENCY 0 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 F4-F4-]- V. a -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ Wx b indicate 1 SELF INSURED =2 GUARANTEE 3 INSURANCE 0 4 SURETY BONO 5 LETTER OF CREDIT =6 EXEMPTION (] %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.❑ II.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# gyp✓ LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DIST RICT CO -OPTIONAL Z ( ° rdy/ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A OF SITE IN ONLY, FORM A(5-91) 1OFl0133A-5