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i STATE OF CALIFORNIA .� STATE WATER RESOURCES CONTROL BOARD s 4 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A NA COMPLETE THIS FORM FOR EAC FACILITY/SITE MARK ONLY � 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ] PERMANENTLY CL ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDFI NEAREST CROSS STREET PAflCELA(OPTA1NAu Al. , CITY NAMESTATE ZIP ODE SITE PHONE#WITH AREA CODE SIZG CA TO INDICATEI/ BOX COflPoRATION LSI INDIVIDUAL 0 PARTNERSHIP � LOCAL-AGENCY 0 COUNTY-AGENCY O STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR [-�i qV IF INDIIAN ON #OF TANKS AT SITE E.P.A. I.D.N(gNicnal) AT 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANOS / EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODEDAYS: NAME(LAST.FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION r MAILINGORSTREETADD� ✓ box bintlicale D INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY 77 =CORPORATION = PARTNERSHIP COUNTYAGENCY FEDERAL-AGENCY CITY NAME STATE ZIP DE PHONE#WITH AREA CODE S o . K-tovL. C a a-- III. TANK OWNER INFORMATION.(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ Wo 0Imhab 0 INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY 0 CORPORATION Q PARTNERSHIP O COUNTVAGENCY 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 14141- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box W Mkm O 1 SELF INSURED 0 2 GUARANTEE O 3 INSURANCE 0 4 SURETY SONO 5 LETTER OF CREDIT E::]6 EXEMPTION Ij 99 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 BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L= II.F—] 111.[:7] THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAM E(PR IN TED&SIGNATURE) APPLICANTS TITLE DATE MONTWOAYiYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# ACIL(TY# LOCATIO O -OPTIONAL CENSUS TRACT OPTIONAL SUPVISOR.OISTRI O THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SrrE I F RMATION0pILY. FORMA(591) F 0011