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`m-� 1490,STATE OF CALIFORNIA e�,o�.« STATE WATER RESOURCES CONTROL BOARD Y�� e's UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A _ COMPLETE THIS FORM FOR EACH FACILITY/SITE '� ' 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION C MARK ONLY E] T PERMANENTLY❑ ❑ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAR ST CROSS STREET PARCEL r(OPTI ) CITY N �^- STATE ZIP CODE SITE PHONE M WITH AREA CODE J CA ✓BOX CORPORATION Q INDIVIDUAL D PARTNERSHIP D LOCAL-AGENCY D COUNTY-AGENCY' O 5 TE-ADEN Y' ED FEDERAL-AGENCY' TO INDICATE DISTRICTS M owner of UST'sa WWI:agency,=plete the fokwittr name of upervsorol drveian,s Ion oroffire whirh op.mm the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓IF INDIAN J#OFTANKSATSITE I E.P.A. I.D.A(apdonap RESERVATION 0 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE NIGHT& NATAE(LOST,FIR PH E WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boeW mQrate D INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY O CORPORATION O PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ fnelontliwte Q INDIVIDUAL Q LOCAL-AGENCY D STATE AGENCY O CORPORATION O PARTNERSHIP O OOUNTY-AGENCY D FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 it questions arise. TY(TK) HQ 744--1 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓Dox to IMicate i SELF-INSURED =2 GUARANTEE =3 INSURANCE =4 SURETY BOND O 5 LETTEROFCREDR O 8 EXEMPTION =7 STATE FUND (] 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND&CERTIFICATEOF DEPOSIT = 10 LOCAL GOVT.MECHANISM O 99 OTHER - V1. 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.❑ 11.E—] III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAY/YEAR I I LOCAL AGENCY USE ONLY COUNTY M JURISDICTION x FACILITY# LOCATIONC E-OPTIONAL CENSUSTRACTN -01�ZONAL SUPVISOR-DISTRICT CODE - PTIONAL cl, 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 -4 THE LOCAL AGENCY IMPLEMENTING THE UNDERGROISTORAGE TANK REGULATIONS FORM A(6-95) 's r � .J