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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE `irr MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE 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 / r ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) -T� CITY NAME STATE ZIP CODE SRE PHONE#WITH EA CODE GD' CA 3 _ ✓BOX O CORPORATION 0 INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY' Q STATE-AGENCY' DE FENAI.-AGENCY' TO INDICATE DISTRICTS H ownerd UST 4 e public agency,complete the following Imine of super isorof dMsion,sedan oroKa which operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTORO ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST, IR T) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE D y NIGHTS: NAME(LAST,FI PHONE#WITH AREA COD NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION /40L--r MAILING OR STREET AD DRE S ✓ box to k4cate INDMWAL LOCAL-AGENCY O STATE-AGENCY J� CORPORATION O PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STAT ZIP CODE PHONE#WITH AREA CODE Go/,r 4 1 q III. TANK OWNER INFORMATION.(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION s DREr �a, ' MA NG OR STREET ADSS ✓ boxlo n##ala OINOIMDUN. LOCAL-AGENCY STATE-AGENCY O . E3 CORPORATION O PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE Gaol qzpq) _ y IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓bozb#akete I� I SELF-INSURED O 2 GUARANTEE =3 INSURANCE O 4 SURETY BOND O 5 LETTER OFCREDIT O 6 EXEMPTION D 1 STATE FUND B STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT O to 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.❑ II.❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHiDAV/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE-OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT L 'ORMORE PEflmrr APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORPW THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO FORM A(6-95) STORAGE TANK REGULATIONS