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• 0 / STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE I MARK ONLY F__j 1 NEW PERMIT O 3 RENEWAL PERMIT [:] 5 CHANGE OF INFORMATION D 7 PERMANENTLY�SEP-91TE ONE R 0 F-1EM 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE SS L FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) `--� DBA OR FANAME DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NAME OF OPERATOR PITY Grsis�t 'n ns ZIP CODE PHONE # WITH AREA CODE ADDRESS NEAREST CROSS STREET PARCEL # (OPTIONAL) CITY NAME STACA ZIP CODE SITE PHONE #WITH AREA CODE C S oz_ BOX TOINDICATE D CORPORATION = INDIVIDUAL Q PARTNERSHIP LOCAL -AGENCY COUNTY -AGENCY' STATE -AGENCY' 0 FEDERAL -AGENCY' 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 o 1 GAS STATION 0 2 DISTRIBUTORRESERVATION TAN�SITE E.P.A. I. D. # (optional) 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS ISOF 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_ PROPFRTY OWNFR INFORMATION - (NWST 6E COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL -AGENCY STATE -AGENCY D CORPORATION PARTNERSHIP (] COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STATE I ZIP CODE PHONE # WITH AREA CODE III. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box b indicate INDIVIDUAL (] LOCAL -AGENCY STATE -AGENCY CORPORATION Q PARTNERSHIP (] COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT TY (TK) HQ M44- - - Call (916) 322-9669 if questions arise. V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPL TED) — IDENTIFY THE METHOD(S) USED ✓ box bindicate = 1 SELF-INSURED 2 GUARANTISC 3 INSURANCE 4 SURETY BOND = 5 LETTER OF CREDIT (] 6 EXEMPTION O 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. E II. D 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 # o LOCATION CODE - OPTIONAL CENSUS TRACT # -OPTIONAL � ISORDISTRICT C9DE - OPTIONAL z-_ 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 REGULATI INS FORM A (3/93) • 101 flT 1� ��