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�aoou x STATE OF CALIFORNIA ` STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A `4eopM COMPLETE THIS FORM FOR EACH FACILRYISITE MARK ONLY F—] 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION LV 7 PERMANENTLY CLO ONE ITEM ❑ 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAO A ILITYNAME NAMEOFOPERATOR ADDRESS NEAR ROSS STREET PARCEL%(OPTIONAL) G � CI N ME STATE ZIP C2)EE SITE PHONE#WITH AREA CODE ✓ sox TOINDICATE O CORPORATION O INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY O STATE AGENCY 0 FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS 0 1 GAS STATION F-1 2 DISTRIBUTOR ✓ IF INDIAN #OF TAN((S AT SITE E.P.A. I.D.%(optional) RESERVATION TVOI 0 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box mindkate INDIVIDUAL I� LOCM-AGENCY I� STATE-AGENCY D CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE%WITH AREA CODE Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREETADDRESS ✓ box blMkale INDIVIDUAL LOCAL-AGENCY D STATE-AGENCY 0 CORPORATION O PARTNERSHIP a COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE%WITH AflEA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 - Z �p V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMP TED)—IDENTIFY THE METHOD(S) USED ✓ box bindicale I SELF-INSURED UARANTEE I= J INSURANCE 1 SURETY BOND D 5 LETTEfl OF CflEgT LVG EXEMPTION O 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: I. II. III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# y�E42 ❑ T�1Tf7al l I. Sl LOCATION C06- TIONAL CENSUS TRACT•_OPT ASUPVISO�-S DIST CODE -OPTIONAL 23 �L✓LI THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANG ,QF�FORMATION ONLY. FORM A(5-91) � / FOR0033&5 (/// fes.