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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE t�. 1 MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION o�orxeniF T CLOS ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I, FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NVE NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) — C L CITY NAME STATE ZIP CODE ITE HONE#WITH AREA CODE 5� 0 CA LS zo - ✓ BOXCORPORATION 0 INDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' 0 FEDERAL-AGENCY' TO INDICATE DISTRICTS If owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR ✓IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.If(optional) RESERVATION 3 FARM Q 4 PROCESSOR O 5 OTHER OR TRUST LANDS JC EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE o - NIGHTS: NAME(LAST,FIRST) PHO'NE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE C —'� KMLF II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Z MAILING OR STREET ADDRESS ✓ box to inclicate INDIVIDUAL LOCAL-AGENCY STATE.AGEN Y 3� CORPORATION PARTNERSHIP COUNTY-AGENCY a FEDERAL-AGENCY CITY NAME STATE ZIP CODEPHONE#WITH AREA CODE � ' G O b2- 73 I — III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-A ENCY 3 Dn CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE C Z- IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions ise. TY(TK) HQ 4 - - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓box to indicate 1 SELF-INSURED =2 GUARANTEE O 3 INSURANCE 0 4 SURETY BOND = 5 LETTER OF CREDIT 0 6 EXEMPTION D 7 STATE FUND 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER O 9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM = 99 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.[D I].X III.a THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT [TANK OWNER'S NAME(PRINTED&SIGNATURE) /� TANK OWNER'S TITLE DATE MONTHiDAYNEAR E d�� (" t 2� LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY It m LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 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 FORN'--'TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGR01""I STORAGE TANK REGULATIONS FORM A(6-95)