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�� • STATE OF CALIFORNIA A D STATE WATER RESOURCES CONTROL BOARD �J EPGR ND STORAGE TANK PERMIT APPLICATION - FORM A e YI O COMPLETE THIS FORM FOR EACH F ITY/SITE MARK ONLY ❑ 1 NEW PERMIT D RENEWAL PERMITCHANGE OF INFORMATION 7 PERMANENTLY D SITE ONE ITEM r! 2 INTERIM PERMIT n AMENDED PERMIT B TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME / NAME OF OPERATOR S wT CU // ADDRESS NEAREST CROSS STREET PARCEL#(OPrIONAL) CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE cA ✓ BOX TO INDICATE O CORPORATION Q INDIVIDUAL O PARTNERSHIP LOCAL.AGENCY Q COUNTY-AGENCY Q STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS O 3 GAS STATION Q 2 DISTRIBUTORO '/ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a(optima) RESERVATION O 3 FARM O A PROCESSOR 0 S OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓hoabultlieLe OINDIVIDUAL 0LOCAL-AGENCY STATE-AGENCY 0 fARPoRATION O PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE III. TANK OWNER INFORMATION- (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS- Coa 0mkaw O INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY 2 2 O CORPORATION PARTNERSHIP 0 COUNrY.AGENCY a FEDERAL-AGENCY CITY NAME- STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ L4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓Cor binCkala I SELF INSURED O 2 GUARANTEE 0 3 INSURANCE d SURETY BOND s LETTEROFCREDIT 6 EXEMPTION N 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 BO%INDICATING WHICH A80VE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. IL a 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&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY -T—P, C-3 - a JURISDICTIONa FACILITY 5-AA)� Z 7 /y L LOCATION CODE OPTIONAL ICENSUSTRACT0 -OPTIONAL SUPVISOR-DISTRICT CODE -OPT ONAL L� THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF SITErrpFOR0123A TI NONLY. 0 FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS Rfi0 0