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• • PeSOUR e C STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a u. C�(IfOP N.r MPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL`PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBfV FACILITY NAMENAME OF OPERATOR reC1 5I SCYUlc� AD RESS �y /1�/ NEAREST CROSS STREET PARCEL#(OPTIONAL) 1.mktJf �J'wG/f I e CI NAMEr STATE ZIP CODE SITE PHONE A WITH AREA CODE Al CA ✓ BOX TO INDICATE CORPORATION 0 INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY ll COUNTY-AGENCY (] STATE-AGENCY (] FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR / IF INDIAN 1#OF TANKS AT SITE E.P.A. 1.D.#(optional) RESERVATION O 3 FARM 4 PROCESSOR O 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 r.0nF NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY Q CORPORATION PARTNERSHIP (]COUNTY-AGENCY 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 INDIVIDUAL LOCAL-AGENCY (] STATE-AGENCY (�CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 -� 0 ,31 g 2 1 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box to indicate 0 t SELF-INSURED E-1UARANTEE E�] 3 INSURANCE 4 SURETY BOND 5 LETTER OF CREDIT Lv6 EXEMPTION 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.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION D -OPTIONAL CENSUS TRACT# -OPTIONAL/ SUPVISOR-DISTRICT CODE -OPTIONAL 22 THIS F RM UST BE ACCOMPANIED BY.AT LEAST(i)OR MORE✓PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) FOR0033A-5