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. • oco�" e STATE OF CALIFORNIA t e�; .Y STATE WATER RESOURCES CONTROL BOARD i Ya�Y o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A � „ a Y IfO11Y� COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ Z PERMANENTLY CLOSED 5 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR FA IUTYN MEalg7 _ NAME OF OPERATOR ADDRESS n NE ST CRO STREET PMCELM(OPTpNAy 350-7V\ CITY NAME STATE ZIP-14 CODE SITE PHONE%WITH AREA CODE G CA a� TO,/ BOX O CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY [71COUNTY-AGENCYSTATE-AGENCY FEDERAL-AGENCY D5TRICTS TYPE OF BUSINESS I GAS STATION 2 DISTRIBUTOR ✓ IRINDIAN %OF �AT ITE E.P.A. LD.%(optional) ❑ ❑ RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER ORTRUSTLANI EMERGENCY CONT CT PERSON (PRIMARY) EMERGENCY C TACT PERSON (SECONDARY)-optional DAYS: NAME E(LAST.FIRST) PHONE%WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE WITH APFA Cl1OF NIGHNAME (LAST,FIRST) PHONE%WITH AREACODE NIGHTS: NAME(LAST,FIRST/ 11, PROPERTY OWNER INFORMATIO MUST BE COMPLETED( CARE OF ADDRESS INFORMATION NAME MAILINGOR STREET ADDRESS ✓ box oindicate 0INDIVIDUAL LOCAL-AGENCY [1] STATE-AGENCY 0 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE%WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE CO LETED) NFORMATION NAME OF OWNER CARE OF ADDRESS I MAILING OR STREETADORESS ✓ box0 fld"'a = INDIVIDUAL L__j LOCAL-AGENCY STATE-AGENCY =CORPORATION 0 PARTNERSHIP [__J COUNTY-AGENCY FEDERAL-AGENCY CITY NME STATE ZIP CODE PHONE%WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUN UMBER-Call(916)323-9555 if questions arise. TY(TK) HO 14L4]-n� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE CO LETED)—IDENTIFY THE METHOD(S) USED ✓ box bintlicate I SELFINSURED =1 2 G flANTEE [__1 3INSURANCE 4 SURETY BOND O 5 LET ER OF CREDIT 6 E%E TION CJ W OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and filling will be sent to the tank owner unless box I or 11 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 APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE GATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 17_- 3 a _4v LOCATIONC EOPTIONAL '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 INFORMATIOONNbNLY. FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STO�N^A,TIOONNS d340x+Foflo033k—J wtl,