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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ` <t� UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM. A COMPLETE THIS FORM FOR EACHOCILRYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED 5 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I / I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) (o UUAORFARTYNAME NAMEOFOp..—ATOR C ADORE S -Ed /,a, NEA ST ROS RE PARCEL#(OPTN)NAU CITU NAAE STATE ZIP DE � SITE PHON #WITH AREA CODE I/ BOX CA —QaJ5 TOINDICATE a CORPORATION INDIVIDUAL =PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY O STATE-AGENCY O FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(optimal) RESERVATION 3 FARM O 4 PROCESSOR Q 5 OTHER 08 TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NA E(LAST,FIRST PHONE#WITH AREA CODE I DAYS: NAME(LAST,FIRST) v —a1S NIGHTS: NAME(LAST,FIRS PHONE-#WITH AREA CODE NIGHTS: NAME(LAST,FIRST II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION fO S l fc MAILING OR STREET ADDRESS ✓ boa bin.iraU Q INDIVIDUAL = LOCAL-AGENCY O STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY =FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE#WITH ARE—CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION ao MAILING OR STREET ADDRESS ✓ Ooa bi....tale INDIVIDUAL Q LOCAL AGENCY STATEAGENCY CORPORATION 0 PARTNERSHIP ED COUNIYAGENCY Q FEDERAL-AGENCY CITU 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 a 4 - a a V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ boa b Mcm I1 I SELF-INSURED O 2 GUARANTEE Q 9 INSTANCE 5 LETTER OF CREDrr Q 6 EXEMPTION U2.07 l�d SUREIY BOND THER A. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. IL❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAVNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# pA�CILL LOCATION CODE -O WWAL CENSUST CT# -OPTIONAL SUPVISOR-DISTRI ODE -OPTIONAL THIS FOM ST BE ACCOMPANIED BY AT LEAS)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5.91)