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• • yOUe e STATE OF CALIFORNIA .f o STATE WATER RESOURCES CONTROL BOARD 3 UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A m COMPLETE THIS FORM FOR EACHFACILRYISITE C4pen"'' MARK ONLY t NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE ONE REM O 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS / NEAREST CROSS STREET PARCEL#(OPTIONAL) N CITY NAME l) STATE ZIP cobE SITE PHONE#WITH AREA CODE ` n CA I/ BOX TOINDCATE O CORPORATION R�INDIVIDUAL O PARTNERSHIP O LOCAL AGENCY O COUNTYAGENCY' O STATE AGENCY' a FEDERAL AGENCY' DISTRICTS' 'If owner ol UST Is a public agency,complete the following:name of Supervisor of division,section,or office whbh operates the UST TYPE OF BUSINESS Q t GAS STATION 2 DISTRIBUTOR 0 RESERVATION INDDION #OF TANKS AT SITE E.P.A. I.D.#(optimal) 3 FARM 0 4 PROCESSOR [=] 5 OTHER OR TRUST LANDS -' 7 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE Y 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 II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxbindbate INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY CORPORATION 0 PARTNERSHIP O 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 ✓ hox biMbate INDIVIDUAL LOCAL AGENCY STATE AGENCY O CORPORATION E= PARTNERSHIP 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 if questions arise. TY(TK) HQ M44- -F IT = V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box biMkale F-1 t SELF INSURED 2 GUARANTEE Q 3 INSURANCE F]a SURETY BOND = 5 LETTER OF CREDIT 6 EXEMPTION 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.❑ Ill. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'STITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# E-1 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -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. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(393) • FORg033AA7