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CO STATE OF CALIFORNIA "^ STATE WATER RESOURCES CONTROL BOARD i UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "° COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBACaFArILITY NAME A NAME OF OPERATOR ADDE S G_ py NEAREST CROSS STREET PARCEL#(OPnONAL) �' S_ CITY NAME �� STATE ZIP CODE SITE PHONE#WITH AREA CODE Ch CA ✓ BOX TO INDICATE D CORPORATION 0 INDIVIDUAL O PARTNERSHIP LOI AL-AG NCY 0 COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERALAGENCY DICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ / IF INDIAN RESERVATION #OF TANKS AT SITE I E.P.A. I.D.#(optional) 3 FARM ❑ 4 PROCESSOR S OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) =7PHONE#W TH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WI H AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA COOP II. PROPERTY OWNER INFORMATION- MUST B COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box A)lmkale OINDIVIDUAL LOCAL-AGENCY STATE AGENCY 0 CORPORATION D PARTNERSHIP D COUNTY AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPL TED) NAME OF OWNER 1 CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box kindute O INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY 0 CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE OMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box t W4ale 0 I SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 0 4 SUu BOND 0 5 LETTER OF CREDIT D EXEMPTION O W OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notificatio 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 NOTIFI t IONS AND BILLING: I.❑ II.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND T THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAVE(PRINTED&SIGNATURE) 7 AN79 TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY LpP�Z Z COUNTY# JURISDICTION# FACILITY It ap? 5407 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIO�NA`LL SUPVISOR-DISTRICT CODE -OPTIONAL O 6 L�THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) FOR0033A5