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%mof soon e STATE OF CALIFORNIA o" s STATE WATER RESOURCES CONTROL BOARD '��. UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A as e C�t�R011 Y,� COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION TF4T PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) Vt CITY NAME STATE ZIP CODS SITE PHONE#WITH AREA CODE ttxl CA 5 I/ BOX CNDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY O STATE-AGENCY E_ FEDERAL TOINgCATE ORPORATION (]IDISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR �' IF INDIAN❑ RESERVATION #OFT TANKS AT SITE E.P.A. I.D.#(optional)0 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) PHONE I WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE# ITH AREA CODE NIGHTS: NAME(LAST,FIRST) - PHONE a WITH AREA COOF II. PROPERTY OWNER INFORMATION- MUST kE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREETADDRESS ✓bwbind' INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY Q CORPORATION PARTNERSHIP O COUNTY-AGENCY FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III, TANK OWNER INFORMATION-(MUST BE COMPL ED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓boablmd� INDIVIDUAL Q LOCAL-AGENCY [—I STATE AGENCY L:l CORPORATION PARTNERSHIP O COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUN UMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ bor b WkNe O 1 SELF-INSURED D 2 GUARANTEE 1� 6 1 RANCE 0 4 SURETY BOND O 5 LETrER OF CREDIT 6 EXEMPTION 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 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 APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACIL"# pmr LOCATION CO -OPTIONAL CENSUS Tri ACT# -OP ZONAL SUPVISOR-DISTRICT CODE -OP770NAL Cy 41 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS T IS A CHANGE OF SITE INFORM�/ATION ONLY. FORM A(5.91) ` /, / FORBWJA-5