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- �.. T, ;:. a- r# a �¢ N R 4 c STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �• �� 7 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F-71 t NEW PERMIT 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED S E ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT t3 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUSTIE-COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS C NEAREST CROSS STREET PARCEL (OPTIONAL) a t / C t�`G CITY NAME STATE ZIP CODE SITE PHONE s WITH AREA CODE CA Tp 7E O CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' STATE-AGENCY' FEDERAL-AGENCY' DISTRICTS' f h 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 I GAS STATION 2 DISTRIBUTOR a ✓ IF INDIAN s OF TANKS AT SITE E.P.A. I.D.s(optional) RESERVATION 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE I)AYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITH'AREA CODE z, It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION s MAILING OR STREET ADDRESS ✓ box to iMkate E INDIVIDUAL LOCAL-AGENCY STATE-AGENCY CORPORATION (] PARTNERSHIP COUNTY-AGENCY' 0 FEDERAL-AGENCY k CITY NAME STATE /f ZIP CODE PHONE s WITH AREA CODE ? r III. TANK OWNER INFORMATION-(MUST BE COMPLETED) r NAME OF OWNER CARE OF ADDRESS INFORMATION _ r -' MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY CORPORATION (] PARTNERSHIP E::] COUNTY-AGENCY FEDERAL-AGENCY - CITY NAME - STATE ZIP CODE PHONE s WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- - v= V.: PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USEDilvrt', wl tip%to Indicate 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 4 SURETY BOND 5 LETTER OF CREDIT 0 6 EXEMPTION (] 99 OTHER Vl. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked.F z „z CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. 11.0 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 CODE -OPTIONAL CENSUS TRACT s -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL " X;y 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 FORW THE LOCAL AGENCY IMPLEMENTING THE UNDERGROjFRAGE TANK REGULATIONS FORM A(3/93) FOR0033A�17 ; �F.