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eSOUR STATE OF CALIFORNIA t� ' cO? STATE WATER RESOURCES CONTROL BOARD 30 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �p •��l�roA N� COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F 7 PERMANENTLY CLOSED SITE ONE ITEM IV2 INTERIM PERMIT C 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DqnACILITY NAME NAME OF OPERATOR DDDR S � E REST CROSS STREET PARCEL#(OPTIONAL) CITY N STATE ZIP C E 20 SITE PH NE#WITH AREA CODE CA -- I/ BOX TO INDICATE CORPORATION 0 INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR RESERVATIONINDIAN #OF TANKS K AT SITE E.P.A. I.D.#(optional) 3 FARM 4 PROCESSOR 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 a WITH AREA rnnP NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST H COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box ioindicate INDIVIDUAL E::] LOCAL-AGENCY 0 STATE-AGENCY -.11 p [�:]CORPORATION 0 PARTNERSHIP = COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE 7rr_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 0 PARTNERSHIP 0 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 114]- OLIL V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box to indicate I SELF-INSURED0 GUARANTEE 3 INSURANCE 4 SURETY BOND 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 unles ox 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 FIAS 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/DAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# L ?101 LOCATION CQDE OPTIONAL ICENSUS jjiAAC# -yWTIONAL I SUP, _10 AL 01 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FOR B,UNL SS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TK UNDE UND STORAGE TANK REGULATIONS 4 FOR0033A-R6