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� � • esoon e STATE OF CALIFORNIA �^ a STATE WATER RESOURCES CONTROL BOARD i UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETETHIS FORM FOR EACH FACILITYISITE MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE ONE ITEM a 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) D13g FACILITY NAME NAME OF OPERATOR ADDRESS T � NEAREST CROSS STREET PARCEL#(OPTIONAL) C TY NAME STATEZIP�CQDIE / SITE PHONE x WITH AREA CODE CA K D (P TO INDICATE E:j CORPORATION 0 INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY COUNTY AGENCY O STATE-AGENCY FEDERAL-AGENCY DSTRITYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR I= VA DTION IAN x OF TANKS AT SITE E.P.A. I.D.#(optimal) 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERS (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) P NE#WITH AREA CODE DAYS: NAME(LAST,FIRST) P14ONE A WITH AREA F NIGHTS: NAME(LAST,FIRST) PHO Al AREA CODE NIGHTS: NAME(LAST.FIRST) PHIQNP#WITH AREA COQ IL PROPERTY OWNER INFORMATION- MUS BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box b Indicate O INDIVIDUAL I� LOCAL AGENCY I� STATE-AGENCY CORPORATION PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMP ) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS• ✓ be)(bindicale INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY Q CORPORATION PARTNERSHIP 0 COUNTY-AGENCY L-1 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCANUMER16)323-9555 it questions arise. TY(TK) HO 144 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUIDENTIFY THE METHODS) USED O I SELFINSUREO 0 3INSUflANCE I�1 SURETY WND 5 LETrEROFCREDIT I_]99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing wi a 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 BILL G L II. III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY Q COUNTY# JURISDICTION# �FACI�LIT�Y## LOGATION CODE OPTIONAL (CENSUS TRACTx -OPTIO AL SUPVISOR-D TRICTCODE -OPTIONAL 01 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(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 9 FOR0O66Afl6