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'va STATE OF CALIFORNIA :a o^ STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORIl A COMPLETE THIS FORM FOR EA FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAORFACILITYN ME NAMEOFOPERATOR NEA E TCROSS SaTREETro PARCEL#(OPTIONAL) CITY NAME„ STATE IP CODE J( CA O SITE PHONE#WITH AREA CODE ✓ BOX TO INDICATE EVCORPORATION O INDIVIDUAL -I PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY DISTRICTS O STATEAGENCY D FEDEMLAGENCV TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF=TANKS SITE E.P.A. I.D.#(optional ❑ 3 FARM ❑ 4 PROCESSOR OTHER ❑ RESERVATION / OR TRUST LANDS EMERGENCY CONTA ERSON (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) ll. PROPERTY OWNER INFORMATION- UST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS —:V 'D,blMbale O INDIVIDUAL Q LOCALAGENCY �STATE AGENCY CITY NAME O CORPORATION O PARTNERSHIP I� COUNTY-AGENCY O FEDERAL-AGENCY STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE CO LETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS bo blMicale INDIVIDUAL O LOCAL AGENCY O STATE AGENCY CITY NAME O CORPORATION PARTNERSHIP COUNTY AGENCY = FEDERAL-AGENCY STATE ZIP CODE PHONE#WITH AREACODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ F4-F4]- V. 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ,1 box b INAcate = I SELF INSURED 0 p G AN E Q 3INSURANCE O5 LETTER OF CREDIT J—d PTION 4 SUREBOND E%EMQ 9B OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to thetank 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 NAM E(PR INTED&S IGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY E �C�,.00LIN..(TYY# JURISDICTION# F-AAC.I�IL.ITYTTYYY##_IF��`—� LOCATID CODE -OPTIONAL CENSUS TRACT# -OPTfO AL SUPVISOR-DISTRICT CGDE -OPT/ONA-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) • �/�� /�r� �� FOf10033A-5