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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 MARK ONLY C 1 NEW PERMIT 3 RENEWAL PERMIT F7 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL A (OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE x WITH AREA CODE CA ✓ BOX n CORPORATION C INDIVIDUAL I= PARTNERSHIP LOCAL -AGENCY COUNTY -AGENCY' STATE -AGENCY' FEDERAL -AGENCY' TO INDICATE DISTRICTS' ' II owner of UST is a public agency, mmple(e the following: name of Supervisor of division, section, or office which operates the UST TYPE OF BUSINESS = 1 GAS STATION J 2 DISTRIBUTOR ✓ IF INDIAN s OF TANKS AT SITE E. P. A. I. D. s (optimal) RESERVATION C 3 FARM C 4 PROCESSOR = 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST. FIRST) PHONE i WITH AREA CODE DAYS: NAME (LAST. FIRST) PHONE e WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE x WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE I WITH AREA CODE II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box R)inaleate INDIVIDUAL _ LOCAL -AGENCY STATE -AGENCY CORPORATION PARTNERSHIP COUNTY -AGENCY J FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE x WITH AREA CODE III. I ANK UVVNtH ft-UHMA I IUN - (MUb I tit C:UMt'Lt I LU NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL C' LOCAL -AGENCY L_; STATE -AGENCY CORPORATION PARTNERSHIP Q COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE rl WITH AREA CODE i IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 it questions arise. TY (TK) HQ j 4 4- - S V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box to indicate I SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND 5 LETTER OF CREDIT 6 EXEMPTION J 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. FCIECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. =i 11,77 III. CI 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 TrrLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # FACILITY r LOCATION CODE - OPTIONAL CENSUS TRACT t • OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS M A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATM FORM A (3W) FOR0015A A7