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aeOV, STATEOFCAUPORNIA ,! ' STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A e! COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY O I NEW PERMIT ❑ 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 0 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE O I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) ORA OR ACILITY NAME NAMEOFOPERATOR G?r cMeali AD RES$ ^� NEAREST CROSS STREET PARCEL#(OPrIONAL) CITY NAO'TM�L a J STATE ZIP CODE SITE PHONE s WITH AREA CODE CA 3.105 TOINDICATE E-1 CORPORATION M INDIVIDUAL (] PARTNERSHIP O LOCAL-AGENCY O couNTY-AGENCY' Q STATE-AGENCY' 0 FEDERAL-AGENCY' DISTRICTS' It owner W UST Is a public agency,conplete the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS O i GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(opl/nnal) O RESERVATION 0 3 FARM O 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#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box loiniaN INDIVIDUAL 0LOCAL-AGENCY STATEAGENCY I 0 CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL AGENCY iCITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ Om lo Indices INDIVIDUAL ED LOCAL-AGENCY O STATE-AGENCY CORPORATION O PARTNERSHIP O COUNTY AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bindle" I SELF-INSURED Q 2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND O 5 LETTER OF CREDIT 6 EXEMPTION 0 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOP LEGAL NOTIFICATIONS AND BILLING: 1. II.E 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'STRLE DATE MONTWDAYIYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# �-T FACILITY# 7 LOCATION CODE -OPTIONAL CENSUSTMCT# - NAL SUPVISOR-DISTRN: CODE -OPTIONAL a , 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 AGFNCY IMPiZMENTING THE UNDERGROUND STORAGE TANK REGULATKINS /'(t)'><j FORM A ISM) Poaom