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# aA STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD v,• o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EAC ACILRY/SITE MARK ONLY ❑ 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION D T P ANENTLY ONE ITEM F-1 2 INTERIM PERMIT 0 4 AMENDED PERMIT E 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR FACILITY NAM - NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAU CITY NAME STATEZIP CODE SITE PHONE#WITH AREA CODE G CA I/ BOX TO INDICATE D CORPORATION 0 INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY COUNTY AGENCY 0 STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS 0 1 GAS STATION Q 2 DISTRIBUTOR I 0 ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.4 Wrlmall RESERVATION 0 3 FARM O 4 PBOCESSOR 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) II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bor bindical# O INDIVIDUAL LOCA4AGENCY 11 STATE AGENCY 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERALAGENCY CITU 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- ✓ bubiMicale 0INDIVIDUAL 0 LOCAL-AGENCY STATE AGENCY 0 CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERALAGEWY 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) HO 14 4 -LSI V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box binJbale [� 1 SELF INSURED 0 2 GUARANTEE O 3 INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT O 6 EXEMPTION 0 W OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or 11 is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[—] I.D III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# j 1 1 ❑ �vj KEs ,3 LOCATIONCODE TONA (CENSUS TRACTA -OPTIONAL SUPVISQ[i-DISTRICT CODI,-OPTION THIS FORM MUS BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TAZ!7-- FOR0073Ag6 •