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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAaILJTY NAME .�1 NAME OF?PE TOR I- LO ADDRES NEAREST C�10S35TREET CELLA(( A / e-r CITY NAME STATE ZIP CODE ITE PHONEa WITH AREA CODE TO Box TE CORPORATION 0 INDIVIDUAL D PARTNERSHIP � UCAL-AGENCY O COUNTY-AGENCY' O STATEAGENCY• O FEDERAL-AGENCY' •N owner of UST Is a public agency.conplele the following:name of Supervisor of division,section.or office which operates the UST TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.R(cplbnal) ❑ ❑ ❑ RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER ORTRUSTLANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE a WIT7AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITGODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ Iba bindkids O INDIVIDUAL (] LOCAL-AGENCY D STATEAGENCY 0 CORPORATION O PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHWTH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓Ombindbam INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY ED CORPORATION Q PARTNERSHIP COUNTYAGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE II 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 bbdbate 0 1 SELF-INSURED =2 GUARANTEE O S INSURANCE D a SURETY BOND =5 LETTER OF CREDIT 0 6 EXEMPTION w 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 �9_ 11.❑ 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 MONTWDAYNEAR LOCAL AGENCY USE ONLY CSOU-NTTYY# JURISDICTION# FACILITY• LOCAT QCODE -OPTIONAL CENSUS TRACTS OP NAL SUPVISOR•DISTRICT CCODDEEOPTIONAL THIS FORM MUST BE ACCOMPANIED BYAT LEAST(1)ORF E�."ASST(1)OR MORE PERMIT APPLICATION• FORM B,UCNLLEES�S THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS4- ` FORMA(3931 `Oa �� A