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STATE OF CALIFORNIA �'� STATE WATER RESOURCES CONTROL BOARD 3 01�, `b o UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A °:w - COMPLETE THIS FORM FOR EACH FACILITYISITE In o 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) DBA OR FACILITY NAME NAME OF OPERATOR L ADDRESS NEAREST CROSS STREET PARCEL (OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE I 'Cf Ca �5ZS ✓ Box [::3 CORPORATION E::] INDIVIDUAL ❑ PARTNERSHIP ❑LOCAL-AGENCY O COUNTY-AGENCY' 0 STATE-AGENCY O FEDERAL-AGENCY' TO INDICATE DISTRICTS #ownerof UST u a pub5c ageaq,complete the loMwing name NsWemalrol SAision,section or office which operates the UST TYPE OF BUSINESSIPQ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A I.D.#(optional) RESERVATION FARM ❑ 4 PROCESSOR ❑ 5 OTHER ORTRUST IANOS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHO E#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE fid / /H4G7� � -5a9 NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE At WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAIL nftaxe LOCAL -AGENCY STATE-AGENCY O/ � CORPORATION PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE D�VJITH AREA C/JDE '^ III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OWNER CARE OF ADDRESS INFORMATION MAIPOR�STREET ADDRESS ✓ baa lonErate ❑ INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY V- as I_1 CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY l71 FEDERAL-AGENCY CITU NAME STATE ZIP cfFj PHONE p WITH AREA CODE rG / L /h IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓boa to hidicate 1:3 1 SELF-INSURED O 2 GUARANTEE ❑3 INSURANCE O 4 SURETYBOND O 5 LEffEROFCREDIT 0 6 ExEMPTION O 7 STATEFUND 08STATE RIND&CHIEF FINMCIALOFRCERLETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT ED 10 LOCAL GOVT.MECHANISM 099 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 TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHrOAV/VEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# m LOCATION CODE -OPTIONAL CENSUST CT# -OPTIONAL SUPVISOR-DISTRICT CODE-OPTIONAL �- Zv A19 7jalf THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROWORAGE TANK REGULATIONS FORMA(6-95)