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cs • e STATE OF CAUFORWA c w^ w STATE WATER RESOURCES CONTROL BOARD i„�� :a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a ACOMPLETE THIS FORM FOR EACH FACILITYISITE +" MARKONLY t NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O ] PERMANENTLY CLOSED 917E _ ONE REM 712 INTERIM PERMIT D X AMENDED PERMIT O S TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) Lj DBA F CILITY NAME NAME OPERATOR i. ADDRESOF S—I4 NEAREST CROSS STREET PARCELA(OPTONAL) CR CITY NAME STATE ZIP SITE PHONE#WITH AREA CODE Box CA a� T NDOATE [:3 CORPORATIONINDIVIDUAL O PARTNERSHIP LOCALAGENCY Q COUNTY-AGENCY' O STATE-AGENCY' O PMERAL#GENCY• DISTRICTS' •N owner d UST Is apudic agency.conplae the Wowing:name of Supewlsor of division,section,or office which operates the UST TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR ' IF INDIAN #OF TANKS AT SITE E.P.A, I.D.#Tcptlanae 0 9 FARM a PROCESSOR Q S OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(UST,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. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxbbdia, = INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY O CORPORATION O PARTNERSHIP O COUNTYAGENCY O FEDERALAGENCY 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 ✓boxb UdkLe INDIVIDUAL O LOCAL AGENCY O STATE-AGENCY O CORPORATION D PARTNERSHIP Q COUNTY-AGENCY D FEDERAL-AGENCY CRY NAME STATE ZIP CODE PHONES 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. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box bIn kats O 1 SELF-INSURED 2 GUARANTEE (]3 INSURANCE O a SURETY BOND 0 5 LETTEROFCREDT O S EXEMPnON D N 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: I.Q II.= III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED a S IGNED) OWNER'S TITLE pATE MCNTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATK)NCODE -OPTIONAL CENSUS TRACT#- TIONAL SUPVISOR-DISTRICT CODE -OPTpNAL o C>13- 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 REGULATIONS i0•�a-�Iq ST�- FORM A(393) 31111