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Qb�q QS f we t• �vi.ii `r STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD W+nom' yb u UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE ONE REM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) r)RA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME STATE ZIP CODE SITE PH NE#WITH AREA CODE CA TOINDCATE 0 CORPORATION Q INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' Q STATE-AGENCY' [�] FEDERAL-AGENCY 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 0 2 DISTRIBUTOR 0 RESERVATION IF INDAN #OF TANKS AT SITE E.P.A. I.D.#(optional) 3 FARM E�j 4 PROCESSOR 0 5 OTHER OR TRUST LANDS r 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 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS �'y� ✓ box b indicate INDIVIDUAL LOCAL-AGENCY STATEAGENCY 49 '6^""4—, CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY CITY NA / STATE ZIP COD _ _` PHONE#WITH AREA CODE e4III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OFF OWNER CARE OF ADDRESS INFORMATION ,v7//g0 MAILING OR STREET ADDRESS / ✓ box to indicate INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY 4a!2:2 `—.4x., CORPORATION PARTNERSHIP GOUNTY-AGENCY FEDERAL-AGENCY CITY NAMESTATE ZIP CODE PHONE#WITH AREA CODE r _. IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ M44- -1 1 1 1 M V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bIndicate 0 1 SELF-INSURED i1 2 GUARANTEE Q 3 INSURANCE 4 SURETY BOND O 5 LETTER OF CREDIT =6 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.[:1 II.El III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CQDE -OPTIONAL ICETf.TW• -OPTIONAL SUP,�I R•DISTRICT CODE -OPTIONAL , , 1 a 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 WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(3/93) Ft]R0033A-117