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(TATE OF CAUPORNIA 'd STATE WATER RESOURCES CONTROL BOARD yam' g UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A COMPLETE THIS FORM FOR EACH FACILRYISITE MARK ONLY ❑ t NEW PERMIT ❑ S RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE I, FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAORFA I NAM NAME OF E ATOR ADDRESS NEAFWSTn S EET PMCELIIOPTIONAL) CITY NAME STA`TTE'G/,! ZIP CODfi`�� SITE PHONE A WITH AREA CODE CA 1,_ ; TORN Box C3 CORPORATION 0 INDIVIDUAL O PARTNERSHIP (] LOGAL-AGENOV I3 COUNTY-AGENCY' E3 STATE-AGENCY' Q FEDERAL-AGENCY' •N owner of UST is a public agency,wnplete the following:name of Supervhor W division.section,or office which operates the UST TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TAN AT SITE E.P.A. I.D.#(opmonal) ❑ ❑ RESERVATION / ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST UWOS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE PHONE#WITH AflEA CODE NIGHTS:NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED CARE OF ADDRESS INFORMATION NAME MAILING OR STREET ADDRESS ✓ bIn bindkate t� INDIVIDUAL 0 LOCAL-AGENCY (] STATEAGENCY 0 CORPORATION 0 PARTNERSHIP 0 coum-Y-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAMEOF WNER CARE OF ADDRESS INFORMATION MAILING OR STREET—ADDRESS ✓ box bindkae = INDIVIDUAL O LOCAL STATE CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE CO ETED)—IDENTIFY THE METHOD(S) USED ✓ box birdkate O 1 SELF-INSURED 0 GUARANTEE Q3 INSURANCE I�4 SURETY BOND 5 LETTER OF CREDIT &EXEMPTION 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. C14ECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ 11.❑ III.❑ 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'S TITLE DATE MONTFVDAYNEAR LOCAL AGENCY USE ONLY �L n CO # JURISDICTION# FACILITY3a FdMI141519 LOCATION CODE -OP L CENSUS T#- T SUPVISOR- T fOIDE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANKR///EGULATWNS FONBNM-R FORM A(3^93)