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1 • ♦Q'Sa u� � O STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e oa COMPLETE THIS FORM FOR EACH FACILR'YISITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OBA `AGILITY NAMED F ERALOR ADORES • NE EST CRO SS ET PARCEL#(OPTIONAL) CITY NAM STATE ZIP SITE PH NE% ITH AREA CODE, CA TOINDBOXICATE CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY I� COUNTY-AGENCV Q STATE AGENCY O fE0ER4L-AGENCY DISTRICTS TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR I❑ qE/ IF INDDION #OF TANNB AT SITE E.P.A. I.D.%(opliana# O 3 FARM O 4 PROCIAN j ESSOR 6 OTHER OR TRUST LANDS / EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODEGAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE%WITH AREA CODE NIGHTS: NAME(LAB I.FIRS T) II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILINGORS ESS ✓ Sox bindkate ] INDIVIDUAL O LOCAL-AGENCY D STATE-AGENCY I]CORPORATION [—I PARTNERSHIP O COUNTY-AGENCY E] FEDERAL-AGENCY CIN 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 b Q INDIVIDUAL O LOCAL-AGENCY (] STATE AGENCY CORPORATION O PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY CIN 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 4 [4-1-[61S2�1 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECOM ETED)—IDENTIFYTHEMETHOD(S) USED ✓ box to mdbale [::] 1 SELF-INSURED ] 2AUARANTEE Q 3 INSURANCE ] 4 SURETY BOND E] 5 LETTER OF CREDIT 94 EXEMPTION 33 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unlessX I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.vII.❑ III.❑ 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 MONTH/DAY/YEAR LOCAL AGENCY USE ONLY G 5 3 COUNTY# JURISDICTION# FACILITY# LDCATION OPTIONAL ICENS T ACT O710NAL SUPVISOR T TCODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITWINFnRMATION FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATION, FOR0033A R6 0 0