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a Pt.OUw<!5 STATE OF CALIFORNIA X01, STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY I NEW PERMIT El 3 RENEWAL PERMIT F—] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE it I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE ADDRESS / NEAREST CROSS STREET PARCEL N (OPTIONAL) PHONE # WITH AREA CODE ZIP CODE PHONE # WITH AREA CODE CIN NAMESTATE ZIP CODE SITE PHONE # WITH AREA CODE CA �' 5 6131/ X01 ? �- U OC ,fib ✓ BOX Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL -AGENCY Q COUNTY -AGENCY' Q STATE -AGENCY' Q FEDERAL -AGENCY' TO INDICATE DISTRICTS If owner of UST is a public agency, complete the following: name of supervisor of division, sedan or office which operates the UST TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN # OF TANKS AT SITE E. P. A. I. D. If (optional) Q 3 FARM Q PROCESSOR Q 5 OTHER RESERVATION OR TRUST LANDS EMERGENCY CONTACT PERSOrvNPRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) PHO # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # ITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE II. PROPERTY OWNER INFORMATION - (MUST B0,-OMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY 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 to indicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY CITY NAME STAT 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 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box to indicate I SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 7 STATE FUND Q 8 STATE FUND & CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND & CERTIFICATE OF DEPOSIT Q 10 LOCAL GOVT. MECHANISM Q 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: I. [�] II. O III. 0 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 LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # FACILITY # 3 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 FORM "TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A (6.95) - ' � /m