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OV A�f'y • STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD , o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A .� COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSQ 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 5 ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) iv U CITY NAME STATE ZIP CODE ITE PHONE#WITH AREA CODE 5CA 9 ✓BOX Q CORPORATION Q INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' Q STATE-AGENCYFEDERAL-AGENCY' TO INDICATE DISTRICTS — If owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST F R Ahf K ��S H 6 E\N 1-L L TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓IF INDIAN I#OFTANKS AT SITE E.P.A. I.D.#(optional) RESERVATION Q 3 FARM 0 4 PROCESSOR Q 5 OTHER OR TRUST LANDS E GENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional D AM PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE o�� NIGHTS: NAME(LAST, IRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE U —U M 1 II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRE S ✓ box to indicate INDIVIDUAL ELOCAL-AGENCY STATE-AGENCY Q CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE HONE WITH AREA CODE S—� C o 2,v - III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION 5 v MA LING OR STREET ADDRESS ✓ box to indicate INDIVIDUALLOCAL-AGENCY STATE-AGENCY IN CORPORATION (� PARTNERSHIP �COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE It WITH AREA CODE C _o C N _1�15 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HOFT_-4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 0 1 SELF-INSURED =2 GUARANTEE 3 INSURANCE =4 SURETY BOND = 5 LETTER OF CREDIT 0 6 EXEMPTION =7 STATE FUND 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM O 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.�� III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK ECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE M/O^�NTWDAYNEAR LOCAL AGENCY USE ONLY �b COUNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL CENSUS T CT -OPT ONAL SUPVISOR-DISTRICT CODE - TIONAL r THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. .J OWNER MUST FILE THIS FORM TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO6STORAGE TANK REGULATIONS %� FORMA(6-95) ' �T �-a3