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STATE OF CALIFORNIA • '`��u-�� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A / / • Yl COMPLETE THIS FORM FOR EACH FACILITYISITE °.... MARK ONLY ❑ 1 NEW PERMIT ❑ O RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ B TEMPORARY SITE CLOSURE 41 I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DILA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL(OPTIONAL) CITY NAME STATE ZIP C004SITE PHONE•WITH AREA CODE v BOX CA 91S,%6 TO INDICATE Q CORPORATION Q INDIVIDUAL Q PAR ERSHIP Q LOCAL AGENCY Q COUNTY-AGENCY 06TRICTS Q STATEAGENCY Q FEOEML-AGENCY TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR � ✓ IF INDIAN 9 OF TANKS AT SITE E.P.A. L D.a(aptipMl) RESERVATION Q 7 FARM G s PROCESSOR ❑ 5 OTHER pq TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional FAYSTSNAME(LAST,FIRST) PHONE A WITH AREA COCF3 DAYS: NAME(LAST,FIRST) : NAME(LAST,'rl ST) PHONE A WITH AREA COOS NIGHTS: NAME(LAST,FIRST) PWONF A WITH ARP A OnDF ll. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boA RlMlap Q INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEOERAL.AGENCY CITU 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 ✓ Om 0Y " Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE&WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. TY(TK) HQ F4-T4]- V. 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED V Em III MINI* Q I SELF-INSURED Q 2 GUARANTEE Q 3 WSURANCE Q F CREDT Q A SURETY BOND 5 IETTERO Q&EXEMPTION Q 9S 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. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD 9E USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ IL❑ 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 MONTHOAYNEAR LOCAL AGENCY USE ONLY s COUNTY A h JURISDICTION M FACILITY N u] GOUIITI V LOCATONCODE OPTIONAL CENSUST G�A rNAL SUPVISOR•DISTflICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FO'IM A(5.91) FOROM3A.5