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• • p,6ppR�ES STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a��" �O C�[IIpp N"� COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY [/2 EW PERMIT L] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F—] 7 PERMANENTLY CL ONE ITEM NTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DB TY NA NAME OF OPERATOR 01111011100w_ % ADD NEAREST CROSS STREET PARCEL#(OPTIONAL) My 6-y' CITY NA STATE ZIP CLQ ZLV) SITE PHONE#WITH AREA CODE CA BOX [`�`1 TO INDICATE CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR0 RESEIF RVATION #OF TANKS AT SITE I E.P.A. I.D.#(optional) 3 FARM O 4 PROCESSOR = 5 OTHER OR TRUST LANDS 3 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONF#WITH AREA rnr)F PHONE WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box ioindicate INDIVIDUAL Q LOCAL-AGENCY STATE AGENCY CORPORATION 0 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 Io indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY CORPORATION PARTNERSHIP COUNTY-AGENCY 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 L4141- '4 q-1,4211 191 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP TED)—IDENTIFY THE METHOD(S) USED ✓ box to indicate �_� 1 SELF-INSURED 0 UARANTEE 0 3 INSURANCE 0 4 SURETY BOND 5 LETTER OF CREDIT V-1 EXEMPTION L] 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.r—] II.D 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 MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY ItMW JURISDICTION# FACILITY# LOCATION CODE OPTIONALCENSUS TRACT#6 0 TIO SUPVISOR-DISTR CT O E -OPTIONAL 01 0 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0033A-R6 __ 1