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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD N` // UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE ONE ITEM Q 2 INTERIM PERMIT 0 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FAC LITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) i Am ink 9, CITY NAME STATEZIP CODE PHONE#WITH AREA CODE d\) CA ✓ lOX ICA CORPORATION INDIVIDUAL = PARTNERSHIP (] LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCY' FEDERAL-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 ' TYPE OF BUSINESS jam( 1 GAS STATION = 2 DISTRIBUTOR 0 RESERVATION INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) 0 3 FARM 4 PROCESSOR 0 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; 1!RS4 PHONE#WITH AREA CODE 1-1 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: N (LAST,FIRST) PHONE#WITH AREA CODE if. PROPERTY OWNER I RMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to Indicate F-1 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY CORPORATION = PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE PLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATIO UST STORAGE FEE ACCOUNT NUMBS Call(916)322-9669 if questions arise. TY(TK) HQ K4]- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDE FY THE METHOD(S) USED ✓ box ioindicate D 1 SELF-INSURED Q 2 GUARANTEE 3 INSURANCE 4 SURETY BOND O 5 LETTEROFCREDIT Q 6 EXEMPTION 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the t owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.F7 II.= 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 MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION#gel:-+ FACILITY#e� 6 V LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL SUPVISOR-DISTRICT CODE -OPZIOAW © 1 (913 s 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 REGULA FORM A PW) � 1