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• nL9a„wCC f STATE OFCALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A •;w „ V ry% . COMPLETE THIS FORM FOR EACH FACILRYISITE X — MARK ONLY F71 NEW PERMIT ❑ 3 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE 5 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OBA OR ILI NAME / I�� NAMEOFOPERATOR ADORE I/"' K NEAREST CROSS STREET PARCEL#IOPfgNAq moq> e, D ab�o CITY NAME STATE ZIP CODE SITE PHONE Al WITH AREA CODE 5 GK` V-r\ CA TO I/ Box O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN #OF TANK T SITE E.P.A. I.D.#(opaanal) ❑ ❑ RESERVATION ❑ 3 FARM ❑ d 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) PHnNE a WITH AREA COOP NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) H II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING ESTREFTRESS ✓ box bim1cm INDIVIDUAL LOCAL-AGENCY 0STATE-AGENCY CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAUAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box 0 WIC a INDIVIDUAL (] LOCAL-AGENCY 0 STATE-AGENCY O CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box mindkale O 1 SELF-INSURED 0 2 GUARANTEE SURANCE [--1d SURETY 80ND O S LETTEROFCREDIT 0 6 EXEMPTION CV99 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 APPLICANTS NAM E(PR IN TED B SIGNATURE) APPLICANT'S TITLE OAT E MONTHIDAYNEAR LOCAL AGENCY USE ONLY """" COUNTY# ��n� JURISDICTION# FACILITY# LOCATION CO E -OPTIONAL CENSUS TRACT# T3NAL SUPVISOR-DISTRICT CODE -OPTIONAL RMTHIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. s FORM A(5.91)