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STATE OF CALIFORNIA �e� '" °+, 2 STATE WATER RESOURCES CONTROL BOARD ; UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ;�� e r .y oa COMPLETETHIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 3 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE 'W7 I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) DBAORr^TFACILIT//Y NAME (( NAME OF OPERATOR `I ( N of S ADDRESS4 - NEAREST CROSS STREET PARCEL#(OPrIONAL) —7 ' /` CITY NAME STATE ZIP CODE SI PHO E#WITH AREA CODE I/ BOX TO INDICATE O CORPORATION 0 INDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY Q COUNrY-AGENCY 0 STATE-AGENCY Q FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 4 GAS STATION U 2 DISTRIBUTOR ❑ RESERVATION #OF TANKS AT SITE E.P.A. I.D.#NtplianalJ ❑ 3 FARM ❑ 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) ?14 7t / �d h ' ({ C7PHONP WITH AREA CODE f / NIGHTS: NY AME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) !1 ryLr 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION G ink MAILING OR STREET ADDRESS` ✓ box tDiMkal# E7:1 INDIVIDUAL [-j LOCAL AGENCY O STATE-AGENCY CORPORATION E-1 PARTNERSHIP Ej COUNTY-AGENCY = FEDERAL-AGENCY CITY 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 ✓ box bindkate INDIVIDUAL LOCAL-AGENCY (]STATE-AGENCY [—j CORPORATION O PARTNERSHIP COUNrY-AGENCY O FEDERALAGENCY CITY NAME' - STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. TY(TK) HQ 4] V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bindicate 1 SELF-INSURED O 2 GUARANTEE 3 INSURANCE 4 SURETY BOND O 5 LETTER OF CREDIT 6 EXEMPTION L] 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to thetank owner unless I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION It FACILITY# ATI: HZ 7 '/ LOCATION CODE -OPTIONAL 1 (CENSUS TRAL 2 -,OPTIONAL I SUPVISOR-DISTRICT CODE -OPTIONAL )// / Pu THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, FORM A(1229n FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 0 0 FOR0033A R6