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leW^ [ STATE OFCAUFORNIA STATE WATER RESOURCES CONTROL BOARD W effi ; UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , ,e t 4 COMPLETE THIS FORM FOR EACH FAgLRYISTTE t MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION X7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ a TEMPORARY SITE CLOSUREiz± I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF PERATOR e)1011 ADDRESP01 rAiNEAREST CROSS STREET PARCEL#(OPTIONAU 3 CITY NAME a I ✓ STATE ZIP CODE SITE PHONE#WITH AREA CODE CA ✓ BOXLOCAL-AGENCY TO INDICATE CORPORATION INDIVIDUAL O PARTNERSHIP DISTRICTS' COUMYAGENCV' O STATE-AGENCY' FEDEML-AGENCY' If owner of UST IS a public agency,wmpiele the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS t GAS STATION ❑ 2 DISTRIBUTOR qV RVADTION AN #OF TANKS AT SITE E.P.A. I.D.#IgoHanag 3 FARM ❑ A PROCESSOR ❑ 5 OTHER ORTRUSTLANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(UST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE It. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boa In indicate INDIVIDUAL 0 LOCAL-AGENCY E-1 STATEAGENCY CORPORATION O PARTNERSHIP Q 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 ✓ boa bintlkate INDIVIDUAL O LOCAL AGENCY Q STATE-AGENCY CORPORATION O PARTNERSHIP Q COUNTY AGENCY O FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 it questions arise. TY(TK) HQ F4]-4-]- V. 4- -V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ boa bindbale = f SELF-INSURED O 2 GUARANTEE 3 INSURANCE O 4 SURETY BOND =5 LETTERCFCREDIT =a EXEMPTION SB 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. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 11.❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED B SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# ACILrrY# FTI LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 3 4 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(493) • OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUNWRAGE TANK REGULATIONS FpMIa37A417 ('w'C�y F'41�fit -0141 NA% t�t!'