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UR STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "`o A COMPLETE THIS FORM FOR EACH FACILITY/SITE P ARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) CI DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS rJ V/ ^O A� NEAREST CROSS STREET PARCEL p(OPTIO/NAL) �7 �/ CITY NAME �/ /`F V,Z �b� G�� L— G ��T STATE ZIP CODE SITE PHONE#WITH AREA CODE CA �ZZ� v, ✓ BOX TO INDICATE CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS a 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. D.#(optional) 3 FARM 4 PROCESSOR 5 OTHER O RESERVATION D OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAM ( ST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) (/ . ' NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME / CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate O�!� l� INDIVIDUAL LOCALAGENCY11 STATE-AGENCY CITY NAME (/ v� D CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY STATE ZIP PCCCOO+DE 7 PHONE#WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STRE ADDRESS ✓ box to indicate INDIVIDUAL 0LOCAL-AGENCY 0STATE-AGENCY TY NAME !J EIJ CORPORATION E71 PARTNERSHIP 0 COUNTY-AGENCY E�] FEDERAL-AGENCY STATE ,t 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 [4T4—]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box to indicate 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND O 5 LETTER OF CREDIT 0 6 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. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. 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) APPLICANT'S TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FAC ILI Y , LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS ORM MUST BE ACCOMPANIED AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS ACHANG OF SITE INFORMATION ONLY. FORM A(5-91) l ' FOR0033A-5