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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A /�•> �Q,foa W� COMPLETE THIS FORM FOR EACH FACILRYISITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY C OSED SIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S— I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME _ a NAME OF OPERATOR Q ADDRESS ^ ^� NEAREST CROSS STREET PARCEL#(OFIONAq CITU NAME J, J STATE ZIP COD SITE PHONE#WITH AREA CODE CA I9 5�0 ✓ BOX CORPORATION D INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY D COUNTY-AGENCY D STATE AGENCY FEDERAL-AGENCY TO INDICATE DISTRICTS TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR = RESERVATION INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) O3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREACODE DAYS: NAME[LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION- UST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILINGORSTREET ADDRESS ✓box b indicate 0 INDIVIDUAL 0 LOCAL AGENCY El STATE-AGENCY I�CORPORATION O PARTNERSHIP COUNTY-AGENCY O FEDERAL#GENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COM LETED) NAME OF OW NER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bindicate I] INDIVIDUAL LOCAL-AGENCY STATE-AGENCY I�CORPORATION O PARTNERSHIP COUNTY-AGENCY 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) HQF4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box b indicate 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND (] 5 LETTER OF CREDIT =6 EXEMPTION O W OTHER Vl. 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. It. 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/DAYNEAfl LOCAL AGENCY USE ONLY L COUNTY# JURISDICTION# FACILITY It 16 LCCATIONCODE -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(5-91) FOR0033A 5