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pBOVM � STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD g UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7V/7PERMANENTLY CLOSED SS ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N Q I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAQR FACI ITV NAME NAME OF OPERATOR o ber fi ADDRESS O NEAREST CROSS STREET +PARCEL#(OPTIONAW CITYNAME�+ STATE ZIP DE HONE#WITH AREA CODE +© � CA TO INDICATE O CORPORATION E-1 INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY E-1 COUNTY-AGENCY STATE-AGENCY Q FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RE/ IF INDIAN SERVATION 4 OF TANKS AT SITE E.P.A. I.D.#(optimal) 3 FARM ❑ 4 PROCESSOR X 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DA NAME(LAST,FIR PHONE#WITH AREA COD YS: AME(LAST,FIRST) e 0d NIGHTS: E(LAST.FIRST) PHONE 4 ITH ARE ODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME� er t cK assn. CARE OF ADDRESS INFORMATION � 1n MAILING Op STREET ADDRESS ✓ box biiNicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY 6Q� CORPORATION Q PARTNERSHIP =COUNTY-AGENCY E�] FEDERAL-AGENCY CITU NAM A..i.r STgTE� ZIPC DE' O PHONED IT AREA LADE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CC �F C 7 38 NAME OF OW NFR CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box b INIcate D INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY CORPORATION 0 PARTNERSHIP L—I COUNTY-AGENCY D 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 14141- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bimicate t SELF-INSURED =12 GUARANTEE Q 3 INSURANCE 0 4 SURETY BOND 5 LETrER OF CREDIT O 6 EXEMPTION Q W 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.❑ II. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PR IN TED&SIGNATURE) APPLICANTS TITLE DATE MONTHDAYNEAR LOCAL AGENCY USE ONLY 0 Ars k, a v COUNTY At JURISDICTION# FACILITY## 3TY LOCATION CODE -OPTIONAL CENBUS TRACT# -OPTIONAL SUPVISOR-DI TRICT CGDE -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. FORM A(5-91) FORaa33A-5