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fyyOVM [ STATE OF CALIFORNIA .` [' STATE WATER RESOURCES CONTROL BOARD :e UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A :y ,e COMPLETE THIS FORM FOR EACHFACILITYISITE `'��[V-"" MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR �_ ADDRESS _ NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE CA ✓ BOX LOCAL-AGENCY TO INDICATE O CORPoRA710N "DIVIDUAL PMTNFASHIP DISTRICTS CWMY-AGENCY' O STATE AGENCY' O FEDEMLAGEWY' 'If owner of UST Is a public agency,complete the following:name of Supervisor of dMaon,section,or office which operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN is OF TANKS AT SITE I E.P.A. I.D.#(Optimal) RESERVATION I 3 FARM ❑ 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#WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ' ✓ WbllNicaN E::] INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY ✓.-r- y._ �� (� Q CORPORATION O PARTNERSHIP E:j COUNTY AGENCY =1 FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION ') S MAILING OR STREET ADDRESS ✓ box 0iroobe Q INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY CORPORATION PARTNERSHIP E-] COUMRAGENCY E=1 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ boa bindoate ISELF-INSURED Q 2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND D 5 LETrEROFCREDIT 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: 1.❑ if.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYIYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# 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 THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMA(393) 0 FORWI3AA7