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• • f STATE OF CALIFORNIA :'� c`; STATE WATER RESOURCES CONTROL BOARD 3,,,�� m o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a _ COMPLETE THIS FORM FOR EACH FACILITY/SITE In MARK ONLY ❑ NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA X FACILITY NAME NAME OF OPERATOR ADORE SS � ry , NEAREST CROSS STREET PARCELr(OPTIONAy CITY NAME,.., 'I.VL/ J STATE ZIP CODE SITE PHONE N WITH AREA CODE V CA o C ✓ BOX Q CORPORATION ED INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY' FEDERAL-AGENCY TO TO INDICATE DISTRICTS 8 ormarol LIST Is epiAfr.apenq.milglete the lollow'eig rremed supervisord Qrvisbn,sactionoroHira wBhh operates Na UST TYPE OF BUSINESS ❑ 1 GAS STATION E::] 2 DISTRIBUTOR ❑ RE EIRVATION MOF TANKS AT SITE E.P.A. I.D.N(optional) 0 3 FARM O 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bexlOV&URe [:1 INDIVIDUAL (] LOCAL-AGENCY O STATE-AGENCY O CORPORATION ED PARTNERSHIP O COUNTY-AGENCY 1:2 FEDERAL-AGENCY CITY NAMSTATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxtobdale C::] INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY O CORPORATION F-1 PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME IP CODE PHONE#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 ✓box to Mirate I SELF-INSURED (] 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND 5 LETTEROFCREOF =6 EXEMPTION 0 T STATE FUND 0 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER a 9 STATE RIND&CERTIFICATE OF DEPOSIT = 18 LOCALGOVT.MECHANISM 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: 1.X II.❑ Ill.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK OWNER'S NAME(PRINTED BSIGNATURE) TANK OWNER'S TITLE DATE MONTMiDAV/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION K FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICTC DE -OPTIONAL � T= THIS FORM MUST BE ACCOMPANIED BY AT EAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM °1 H THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUN$STORAGE TANK REGULATIONS FORMA(6-95) •