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• 0 .. STATE OF CALIFORNIA �� oc' STATE WATER RESOURCES CONTROL BOARD Y dam, m UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :s _ COMPLETE THIS FORM FOR EACH FACILITY/SITE rn MARKONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT \J 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO TIE`— ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT Aum• 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR _ ADDRESS NEARESTCR SSTREET PARCEL#(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CA ✓ BOX CORPORATION I2'INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY O COUNTY-AGENCY' STATE AGENCY' FEDERAL-AGENCY' TO INDICATE DISTRICTS If ownerol UST is apublic agenry.complete the following name of eupervisorol dwolon,section or office whish operates the UST TYPE OF BUSINESS V I GAS STATION ❑ 2 DISTRIBUTORRE IF INDIION ANI#OFTANKSATSITE E.P.A. 1.D.#(optional) ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS v' EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST] PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE FI NIGHTS' NAME(LAST, RST) 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 ✓ boxtoicioate I=INDIVIDUAL LOCAL-AGENCY 0STATE AGENCY CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE r PHONE#WITH AREA CODE III. TANK OWNER INFORMATION -(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box loeMrate h INDIVIDUAL O LOCAL AGENCY O STATE-AGENCY r O CORPORATION O PARTNERSHIP O COUNTY AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP COQ PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 74F4--]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to iMP.ale 1 SELF-INSURED Q 2 GUARANTEE [:13 INSURANCE O 4 SURETY BOND O 5 LETIEROFCREDTr =6 EXEMPTION =7 STATE FUND f�9 STATE FUND&CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM 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: L❑ 11.E] III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BESTOF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHiDAYYEAR LOCAL AGENCY USE ONLY C�O�UTNT.�Y'�# JURISDICTION# FACILITY# X4.'gL016�c.c_L L-tie'-� 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. OWNE6 MUST FILE THIS FOR 9H THE LOCAL AGENCY IMPLEMENTING THE UNDERGROOSTORAGE TANK REGULATIONS FORMA(6-95)