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��cWe C STATE OF CALIFORNIA .` .c STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A ��, y COMPLETE THIS FORM FOR EACH FACILITYISITE � `��.a.•" MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED Si ONE REM 7] 2 INTERIM PERMIT 4 AMENDED PERMIT O a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESSNEAREST CROSS STREET PARCEL I(OPTIONAL) CITY NAME_ ) STATE ZIP CODE SITE EP N #WITH AREA CODE VC•/h CA Tp/ BoxTE CORPORATION Q INDIVIDUAL O PARTNERSHIP O LOCAL'AGENCY Q COUNTY AGENCY' STATE AGENCY' (] FEDERALAGENCY' DISTRICTS' '11 owner of UST Is a public agency.odmiete the fallowing:name of Supervisor of division,section,or officewhich operates the UST TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTORR/ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.a(0p0mal) 0 3 FARM 4 PROCESSORCK 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHON #WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE Ride-r . (a;r of NIGHTS: NAME(LAST,FIRST) PHONE74 WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bmianObae = INDIVIDUAL O LOCAL AGENCY STATE-AGENCY D CORPORATION 0 PARTNERSHIP COUNTY AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bow bindkaM INDIVIDUAL O LOCAL AGENCY STATE AGENCY CORPORATION O PARTNERSHIP Q GOUNTYAGENCY Q FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ bot b1micala O 1 SELF-INSURED =2 GUARANTEE = 3 INSURANCE O 4 SURETYlOND D 5 LETTEROF CREDIT [_1 6 EXEMPTION 0 %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. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II.E III.E THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED a SIGNED) OWNER'S TITLE DATE MONTHIDAYYEAR LOCAL AGENCY USE ONLY e a 3 OLf COUNTY# JURISDICTION# FACILITY# alq 1 1111 LOCATION CODE -OPTTONAL CENSUS T CT# - T NAL SUPVISOR-DISTRICT CODE -OPTIONAL U 1 3, Qp THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORWTKNI ONLY. FORM A(30113) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS TOR00 IIA-NK 0311i7