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�eOVa [ STATEOFCAUFORMA ^�[ c B STATE WATER RESOURCES CONTROL BOARD .v� a o UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A :- r o t,.a.N�^ COMPLETE THIS FORM FOR EACH FACILIP/ISITE ( MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SIT ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DSAOR FACILITY NAME _I r NAME OF OPERATOR ADDRESS /,� NEAREST CROSS : I iEET PARCEL ((OPTIONAU CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE > CA BC TO INDICATE D CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY 0 COUNTY_AGENCY' O STATE-AGENCY' O FEDERAL_AGENCY' DISTRICTS' If water of UST Is a public agency.conplate the following:name of Supervisor of division,section,or office which operates the UST VF INTYPEOFBUSINESS ❑ t GASSTATION ❑ 2 DISTRIBUTOR pESERVAT010N NOF TANKS AT SITE E.P.A. I.D.a(npfronal) ❑ 3 FARM ❑ 4 PROCESSOR ❑ 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 s WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME _ _ CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bot ID AM O INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY G Q CORPORATION 0 PARTNERSHIP (] COUNTY_AGENCY O FEDERAL AGENCY CITY NAME j STATE ZIP DE PHONE a WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bot blnEbYe = INDIVIDUAL = LOCAL-AGENCY 0 STATEAGENCY CORPORATION =PARTNERSHIP =COUNTY-AGENCY FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE If WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ bN bintlkaw O l SELF INSURED l=2 GUARANTEE Q 3 INSURANCE L_j 4 SURETY BOND D 5 LETTEROFCREIXT E-3 6 EXEMPTION 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 OWNER'S NAME(PAINTED&SIGNED) OWNERSTITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION If FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THE IS A CHANGE OF SIZE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0033Aa7 FORM A(393) o •