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• N}}OUN N STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ( r UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �e COMPLETE THIS FORM FOR EACH EACILITYISITE MARK ONLY F__j I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PER ANENTLY CL IT ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAM t4 `/ NAME OF OPERATOR ADDRESS I NEAREST CROSS STREET (OPTIONACF— _____F_ AAAA0 CITY NAME STAZIP COD �.�� SITE PHONE#WITH AREA CODE TE ✓ BOX TO INDICATE D CORPORATION O INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY 0 COUNrY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION O 3 FARM O 4 PROCESSOR 0 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) PHONE It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREETADDRESS ✓ box b indicai# INDIVIDUAL 0 LOCAL AGENCY 0 STATE-AGENCY CORPORATION O PARTNERSHIP I—]COUNTY-AGENCY 0 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 Pkat¢ 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY 0 CORPORATION D PARTNERSHIP =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 14:141- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box 0indicate O 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 714 SUREN BOND D 5 LETrEROFCREDT 0 6 EXEMPTION 0 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.F 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# LOCATION CODE -OPTIONAL CENSUS TRACT OPTIONAL SUPVISO -DISTRI TCOD -OPTIONAL V 2 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPL ATION• FORM B ESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(591) _ _ FOR0033A5