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• 0 W. ♦� C STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD + UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILRY/SITE MARK ONLY F__j 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION -] PERMANENTLY CL �S6 t. ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE J .' I. FACILITY/SITE INFORMATION S ADDRESS-(MUST BE COMPLETED) DRA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEU(OPTIIONAL) CITY tANE STATE ZIP CODE SITE PHONE t W LTH AREA CODE CA ✓ BOX TO INDICATE O CORPORATION 0 INDIVIDUAL O PARTNERSHIP O ARLC� CY 0 COUNTY-AGENCY' O STATE-AGENCY' O FEDERALAGENCY' N owner of UST Is a public agency,cmplate the following:name of Supervisor of division,section,or onios which operates the UST TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR / IF INDIIAN ON A OF TANKS AT SITE E.P.A. I.D.a(optional) 0 3 FARM 0 4 PROCESSOR 0 5 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) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: E(LAST,FIRST) PHONE#WITH AREA CODE I. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bac bindbale O INDIVIDUAL D LOCAL-AGENCY O STATE-AGENCY O CORPORATION O PARTNERSHIP D 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 j ✓boo bbdbau, = INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY D CORPORATION 0 PARTNERSHIP D COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV. BOARD OF ECILIALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HO 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ Wa nindnale O 1 SELF-INSURED (]2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND D 5 LETTEROFCREDIT 0 6 ExEMPTION D 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.Q THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED A SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION FACILrTY# c o EM r.. LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPT30NAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SrTE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(3193) l • FOR0033AA7