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• • °°° STATE OF CALIFORNIA � ' s STATE WATER RESOURCES CONTROL BOARD a � 9 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� Y° C�lli°e Mie COMPLETE THIS FORM FOR EACH ILITYISITE MARK ONLY F-1 t NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY ITE ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT L�] 6 TEMPORARY SITE CLOSURE © / I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAORFACILITYN ME /1 NAME OF OPERATOR ADDRES NEAREST CROSS STREET PARCEL#(OFIONAL) CITY NAME / r V T STATE ZIP D� SITE PHONE#WITH AREA CODE -I{'CJ- CA ✓ BOX TO INDICATE E7 CORPORATIONNDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY Q COUNTY AGENCY O STATE-AGENCY 0 FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS O 3 GAS STATION 0 2 DISTRIBUTOR / O */ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#Wimal/ ,LL� OR RESERVATION O 3 FARM O 4 PROCESSOR 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional YS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) - P NI TS: ME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE II. PROPERTY NER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ Wx bindicate Q INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY 0 CORPORATION 0 PARTNERSHIP Q COUNTWIGENCY Q FEDERAI-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MU BE COMPLETED) NAME OF OW NER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate = INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY I�CORPORATION O PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT MBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 - a Q 5 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ We to indicate I SELF-INSURED 2 G ANTEE 3INSURANCE 4 SURETY BOND (]5 LETrEROFCREDIT EXEMPTION 93 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: 1. IL❑ III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR LOCAL AGENCY USE ONLY CO�UmNT%Y�# JURISDICTION# FACILITY Y##�� LOCATION COD -OPTIONAL CENSUST ACT# -OPTIONAL SUPVISORDISTRICTCODE -OPTIONAL 3 a 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(&91) qF.n FOR0033A 5 • A/ • - L - qa �j