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E9��A«S STATE OF CALIFORNIA x�P cO� STATE WATER RESOURCES CONTROL BOARD W , 01 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY C71,7 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS ' NEAR CROSS OSSSSSTRE�E,T ] PARCEL#(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE obnK� CA C) ✓BOX CORPORATIONINDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' 0 STATE-AGENCY' 0 FEDERAL-AGENCY' TO INDICATE DISTRICTS If owner of UST is a public age complete the following:name of supervisor of division,section or office which operates the UST TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR RESERVATION INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) 3 FARM Q 4 PROCESSOR O S OTHER OR TRUST LANDS 6�J' EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAY : NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FI T) HONWITH AREA ODE NIGHTS: NAME(LAST,FIR T) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIW PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFm NAME CARE OF ADDRESS INFORMATION R11 - €S9 - M ILING OR STREET DRESS ✓ bcx to i:c,o *DIViDUAL E::]LOCAL-AGENCY Q STATE-AGENCY 1.010 A Aae, 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP ODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) nNOF OWNE CARE OF ADDRESS INFORMATION iii MAILING OR STREET DR S ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY Ay CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY CI N Er STATE ZIP CODE PHWITH EA CODEA� 4n if r� IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 0 1 LF-INSURED = 2 GUARANTEE 0 3 INSURANCE =4 SURETY BOND 0 5 LETTER OF CREDIT =6 EXEMPTION =7 STATE FUND 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT = 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 check CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= II. III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRI &S AT E) TANK OWNER'S TITLE DATE MONTH/DAYNEAR LOCAL AGEN Y USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY A�(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS IS IS A CHANGE OF SITE INFORMATIO ONLY. FOAM A(6-95) OWNER MUST FILE THIS FO THE LOCAL AGENCY IMPLEMENTING THE UNDERGR TORAGE TANK REGULATIONS