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M %two w�SOURCCs C STATE OF CALIFORNIA E ��• Ger 9 STATE WATER RESOURCES CONTROL BOARD W- Ata UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A y° fCOMPLETE THIS FORM FOR EA FACILITYISITE MARK ONLY L.- 1 NEW PERMIT f� 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY ITE ONE ITEM ._' 2 INTERIM PERMIT I— 4 AMENDED PERMIT El 6 TEMPORARY SITE CLOSURE S3 1. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAACILI^�iNAM ,-,�Jn NAME OF OPERATOR ADDRESS NEAREST CROSS STREET I, PARCEL#(OPTIONAL) _ _� CITY NAME STATE ZIP CODE SIT PH NE#WITH AREA CODE _ — CA ✓ BOX TO INDICATE CORPORATION L-] INDIVIDUAL = PARTNERSHIP [__1 LOCAL-AGENCY Q COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS �� 1 GAS STATION 2 DISTRIBUTOR RESERVATION/ IF INDIAN #OF TANKS AT SITE E-P.A. I D.#(aptiono, n 3 FARM 4 PROCI=SSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional D : NAME(LAST, IRS C of I, ITH AREA CODs, DAYS: NAME(LAST,FIRST) SPHONE n WITH AREA CO[] NIGHTS: NAME{LAST,FIRST) + PHONE POWITH AREA CODE NIGHTS: NAME{LAST,FIRST) PHONE#WITH AREA CODF II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAMECARE OF ADDRESS INFORMATION S- �2--T ✓ box b indicate MAILING OR STREET ADDRESS 1 L_� INDIVIDUAL [] LOCAL-AGENCY STATE-AGENCY 32 f�1 J� ��f_ ©CORPORATION 0 PARTNFRSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NA f4 _ `� 1 ZIP CODED PHONf�#WITH AREA CODE 111. TANK`JFOWNER I/INFORMATION-(MUST BE COMPLETED) fl y^ 5 NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY 0 CORPORATION 0 PARTNERSHIP [] COUNTY-AGENCY FEDERAL-AGENCY CITY NAME _ STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 -f0 a 1qj V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bIndicate L] 1 SELF-INSURED 0 2 GUARANTEE i) 3_,1 RANCE 0 4 SURETYBOND 77 5 LETTER OF CREDIT 6 EXEMPTION OTHFR VL 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 L—] t>4 III.ED THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PR INTED&SIGNATURE) APPLICANT'S TITLE DATE MONTWDAYiYEAR LOCAL AGENCY USE ONLY P COUNTY# JURISDICTION# FACILITY# LOCATION CCOE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL - s%) 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(5-9M1) FOR0033A cv -5