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eeoua � I STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD F UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A g� Y J/-'" C�IiFOXM� COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION EV7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DB R FACILI NAME NAME OF OPERATOR '0 SU NEQi TCROS��CET PARCEL N(OPTIONAL) 466 CITY NAME STATE JJZIP C.•..AA SITE PHONE x WITH AREA CODE CA 52U3 I/ BOX TO INDICATE -1 CORPORATION O INDIVIDUAL = PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY D STATE-AGENCY 0 FEDERAL AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR [=] ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(oplimao RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR ❑ 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) PHONE 9 WITH AREA COn NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COOP II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box binEbate [=l INDIVIDUAL D LOCAL-AGENCY D STATE AGENCY CORPORATION O PARTNERSHIP O COUNTY-AGENCY D FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OW NER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box 0101cate L--1 INDIVIDUAL LOCAL AGENCY STATE-AGENCY E-1 CORPORATION l= PARTNERSHIP D COUNrY-AGENCY E::] FEDERU.-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 F4-T4 D Z V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COM ETED)—IDENTIFY THE METHOD(S) USED ✓ bax In Imicate O 1 SELF-INSURED 0/GUARANTEE Q 3INSURANCE A SURETY BOND l= 5 LETTER OF CREDIT LV 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.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# I JURISDICTION# FACILITY# 75% 13 = I 1 1 ,11 �, U"02'- LOCATION CODE -OP O AL CENSU TIy CT# QftTIWAL SUPVISOR-DISTRIR Z-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