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•L r 0 �tHowc�s co STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD s UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 's , COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION L-17 PERMANENTLY LOSE ❑ ❑ ONE ITEM 2 INTERIM PERMIT 4 AMENCIED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DSA OR FAr NAME NAME OF OPERATO ADDRESS 1 NEST CROSS STREET PARCEL#(OPTIONAL) CITY NAME STATE� ZIP ODE �� SITE PHONEWITH.AREA COQf ✓ BOX ]CORPORATION INDIVIDUAL, PARTNERSHIP []LOCAL-AGENCY ] COUNTY-AGENCY• I] STATE-AGENCYFEDERAL-AGENCY' TO INDICATE DISTRICTS It owner of UST is a public agenry,complete the following:name of supervisor of division,section or office which operates the UST TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION 3 FARM 4 PROCESSOR = E OTHER OR TRUST LANDS 3 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CCCE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFDI NAME a CARE OF ADDRESS INFORMATION bo MAILI G OR SRF ADDRESS ✓ bu to i^d.ca�' -MVIDUAL ] LCCAL-AGENCY I] STATE-AGENCY + , �J ©CORPORATION (�PARTNERSH? CI CCUNTY-AGENCY t� FEDERAL-AGENCY CITY NAME v STATE^ ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) /f�{ NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxto indicate 0 INDIVIDUAL LOCAL-AGENCY ] STATE-AGENCY (]CORPORATION L�j PARTNERSHIP ® COUNTY-AGENCY D 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- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate ] 1 SELF-INSURED I] 2 GUARANTEE I]3 INSURANCE ] 4 SURETY BOND l]5 LETTER OF CREDIT Q& EXEMPTION 0 7 STATE FUND 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER L__] 9 STATE FUND 6 CERTIFICATE OF DEPCSIT = 19 LOCAL GOVT.MECHANISM ] 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. 11. ISI. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME{PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTH/DAYIYEAR LOCAL AGENCY USE ONLY 3 COUNTY# JURISDICTION# FACILITY# ❑ I 1010LT5ma LOCATION CODE -OPTIONAL CENSUS TRA OP7 NAL SUPVISOR-DISJRICT CODE - PTIONAL 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 THE LOCAL AGENCY IMPLEMENTING THE UNDER"STORAGE TANK REGULATIONS FORMA(6-s5) q J( 0� , �w