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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD / UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FA YISITE `'��•a""" MARK ONLY t NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLO 0 elTo ONE REM 2 INTERIM PERMIT O 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE 6 J \' I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY N E OCC NAMEOFOPERATOR E •��e ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 6aNk �• TapXo CITY NAMEC 1 � STATE ZIP CODE SITE PHONE S WITH AREA CODE J � CA ✓ BOX TOINDICATE f�CORPORATION IVIDUAL 0 PARTNERSHIP � LOCAL-AGENCY 0 COUNTY-AGENCY' O STATE-AGENCY' ED FEDERAL-AGENCY' DISTRIN owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESSSTATION Q 2 DISTRIBUTOR RESERVATION/ IF INDIAN #OF TANKS AT SITE E.P.A. I.O.#(apTrona/) 3 FARM 4 PROCESSOR Q 5 OTHER ORTRUSTLANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(UST,FIRST) PHONE#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 NAM \ \ (� �r CARE 01(7DRESS INFORMATICI 5' MAILING OR STREET#DOR SS ✓EoabkWkm D INDIVIDUAL DLOCAL-AGENCY DSTATE-AGENCY S - O CORPORATION = PARTNERSHIP COUNTY-AGENCY O FIEDERALAGENCY 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 bindicate D INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY (]CORPORATION PARTNERSHIP Q COUNTY-AGENCY 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 F4-T4--]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓boa binEkate =i SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE 0 4 SURETY BOND O 5 LETTEROFCREDIT O 5 EXEMPTION O W OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[:] 11.0 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 S SIGNED) OWNER'S TITLE DATE MONTWDAY/YFJR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OP 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 FORM A RM) • FOfl0033AA7