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• C� STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE tSpV�CCS APP IV�Ir,, Opy i 3 m , � do • C�I�fON N�f MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED. SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1- FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NA' E NAME OF OPERATOR /AI r ,-- -7 ADDRESS NEAREST CROSS STREET PARCEL # (OPTIONAL) NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE ai f ce -z406 STATE A CITY NAME STATE ZIP CODE SITE PHONE # WITH AREA CODE GOD CA ✓ BOX CORPORATION INDIVIDUAL D PARTNERSHIP LOCAL -AGENCY COUNTY-AGENCYSTATE-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 M 1 GAS STATION 2 DISTRIBUTOR a ✓ IF INDIAN 1# OF TANKS AT SITE E.P.A. 1.0.#(optional) 0 3 FARM O 4 PROCESSOR 0 5 OTHER RESERVATION OR TRUST LANDS FMFftGFNCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - ootional DAYS: NAME LAST, FIRST) PHQNE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE -7 0 �2 ©'`r ) 9 uP — I t/ box to indicate 0 INDIVIDUAL LOCAL -AGENCY C] STATE -AGENCY NIGHTS: NAME (LAST, FIRST) ONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE ai f ce -z406 STATE A II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION -(Al MAILING OR STREET ADDR S t/ box to indicate 0 INDIVIDUAL LOCAL -AGENCY C] STATE -AGENCY J % 4) I = CORPORATION = PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STATE A ZIP CODE PHONE # WITH AREA CODE �'� T✓ PHONE # WITH AREA CODE fly^{�� V �" 'i,....4 III- TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION CARE -(Al MAILING OR STREET ADDSS ✓ box to ndipte 0 INDIVIDUAL LOCAL -AGENCY STATE -AGENCY - t? CORPORATION 0 PARTNERSHIP 0 COUNTY -AGENCY 0 FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE fly^{�� V �" 'i,....4 - IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. TY (TK) HQ4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box to indicate 0 1 SELF-INSURED 0 2 GUARANTEE = 3 INSURANCE = 4 SURETY BOND 0 5 LETTER OF CREDIT = 6 EXEMPTION 0 7 STATE FUND D 8 STATE RIND & CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND & CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT. MECHANISM 0 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. ❑ it. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME (PRINTED & SIGNATURE) TANK OWNER'S TITLE DATE MONTHiDAY/YEAR LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # FACILITY # LOCATION CODE -OPTIONAL CENSUS TRACT # -OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL (::;'z- - ,, X 15 S241;1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS 15 A CHANGE OF 511 t INFUHMA I wri UNLT. OWNER MUST FILE THIS FORON THE LOCAL AGENCY IMPLEMENTING THE UN DE STORAGE TANK REGULATIONS FORMA (6-95) ,