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eeoun � STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ` UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANEN CLOSED SI ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE S I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR FACILITY NAhtF� NAMEOFOPERATOR /1//14 / ADDRESS NEAREST CROSS STREET PARCEL N(OPTIONAL) ss Y�CI � CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE A dr CA f5366 ✓ Box TOINDICATE 0 CORPORATION 0 INDIVIDUAL I=PARTNERSHIP Q LOCAL-AGENCY O COUNTY AGENCY Q STATE-AGENCY O FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS O t GAS STATION 2 DISTRIBUTORO ✓ IF INDIAN J#OF TANKSAT SITE E.P.A. I.D.#(optimal) RESERVATION 3 FARM 0 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) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA COOF II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION h 42 MAILING OR STREET ADDRESS ✓box b indicate = INDIVIDUAL LOCAL AGENCY STATE AGENCY Sb S Iq D CORPORATION Q PARTNERSHIP Q COUNTY AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE i 9 S 3 111. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR ST EET ADDRESS ✓ box Aindicate 0INDIVIDUAL LOCAL AGENCY Q STATE-AGENCY O t7 ' Z C-D J 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 F4-F4]- D 9 V. PETROLEUM UST FINANCIAL RESPONSIBILITY• (MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ box bindloate - I SELF INSURED 0 2 GUARANTEE 0 ]INSURANCE 0 4 SUREN BOND 5 LETTER OF CREDIT D 6 EXEMPTION O 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.❑ II 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 MONTWDAYIYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# I<lv4rT ss BE I I 1 11 LOCATION CODE -OPTIONAL CENSUS TRACT( -OPTIONAL SUI-DISTRICT CODE -OPTIONAL 19 o - S- SZ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(5-97) / FORW77Ad' /V (-/�/