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't60uR f < STATE OFCALIFORMA W '^ STATE WATER RESOURCES CONTROL BOARD w,,,� • . e _ UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A „oR�,�' COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 0 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION III ADDRESS-(MUST BE COMPLETED) DBAO CILITY OE _ /� - NAME OF OPERATOR /VC/C— NEAR CROSS STREET PARCEL*(OFIONAL) IV 55.5 /n ADDRESS CITYNAME STATE ZIP C$K1EE SITE PHONE#WITH AREA CODE (/� G T 10 NDICRTE 0 CORPORATION Q INDIVIDUAL PARTNERSHIP 0 LO AL-AGENCY COUNTY-AGENCY I�STATE-AGENCY FEDERAL AGENCY RICTS TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR = V IF R SERVATION #OF TANKS AT SITE I E.P.A. 1.D.#(00map 0 3 FARM O 4 PROCESSOR 0 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) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) DUAKIE If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓boxbindwa O INDIVIDUAL O LOCAL AGENCY 0 STATE-AGENCY l�CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY 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 %/ box binOkap 0 INDIVIDUAL OLOCAL-AGENCY (] STATE-AGENCY CORPORATION 0 PARTNERSHIP O COUNTY AGENCY FEDERAL-AGENCY 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 4 4 Z 3 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE CO ETED)—IDENTIFY THE METHOD(S) USED ✓ box biNlkale 0 ISELF-INSURED GUARANTEE I1 3INSURANCE 4 SURETY SONO 5 LETrEROFCREDIT 6 EXEMPTION O 93 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: I.O 11.= H. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY x JURISDICTION p FACILITY n LOCATION CO OPTIONAL CENSUS TRACT•_-OPTJQ/YfL SUPVISOR-DI�RICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM BB,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) FORMA-5 /&_ %Vd.