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• STATE OF CALIFORNIA • <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT g 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA O FACT TY NAME OF OPERATOR <br /> ADDRESS a NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓BOX O CORPORATION O INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY <br /> TO INDICATE OCOUNTY-AGENCY' OSTATE-AGENCY' OFEDERAL-AGENCY' <br /> DISTRICTS <br /> M ownerol UST Is xy <br /> a polGc agm ,mmplMe the fo9owhg name d sM>arvisord tlrvbhn,sedan oro#rce wfiitli operates the UST <br /> TYPE OF BUSINESS ❑ i GAS STATION ❑ 2 DISTRIBUTOR Q ✓IF INDIAN I#OF TANKS AT SITE E.P.A. I.0.#(opt!..1) <br /> ❑ 3 FARM ❑ a PROCESSOR 5 OTHER OR TRUBT RESERVATION LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY-CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE Y WITH AREA CODE DAYS: NAME( ,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIG : NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETE <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box lohdaale OINDIVIDUAL LOCAL.AGENCY =1STATE-AGENCY <br /> =CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxto htli[ale OINDIVIDUAL OLOCAL-AGENCY OSTATE-AGENCY <br /> D CORPORATION PARTNERSHIP 0 COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box binRcab = 1 SELF-INSURED 0 2 GUARANTEE Q 3 INSURANCE Q#SURETYBOND 0 5 LETTEROFCREDIT 0 S EXEMPTION O 7 STATEFUND <br /> O S STATE RIND It CHIEF FINANCIAL OFFICER LETTER 09 STATE FUND A CERTIFICATE OF DEPOSIT = 19 LOCALGOVT.MECHANISM 0 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ it.O III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BESTOF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAWYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUSTRACT#-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6-95) OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 1-3 - q -7 �L, <br />