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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Q 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 NAME OF OPERATOR kill ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) Q 14 A CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CA p ✓ BOX CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY D COUNTY-AGENCYSTATE-AG CY' FEDERAL-AGENCY' TO INDICATE DISTRICTS It 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 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT!7.A. I.D.#(optional) RESERVATION 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS 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 NIGH AME ST,FIRST) O E#WI R C IGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY =CORPORATION PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER 7'OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY =CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE 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 1 SELF-INSURED = 2 GUARANTEE 0 3 INSURANCE = 4 SURETY BOND = 5 LETTER OF CREDIT = 6 EXEMPTION 0 7 STATE FUND 0 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =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.= II.❑ 111.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 LOCAL AGENCY USE ONLY �//j_ COUNTY# JURISDICTION# FACILITY# 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 UNDERGROIImn STORAGE TANK REGULATIONS FORMA(6-95) Aw