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OJF f9 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EAC ACILITY/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) DBA OR FAIT'YNAME NAMEOFOPFVRAALT/OLR ADDRESr „ a"�r NRR;ESTC SS STRE PARCELN(OPTIONAL) r CITY NAME �DSTATEA ZIP CO E SITE PHONE#WITH AREA CODE I/ BOX 31- M TO INDCATE I l CORPORATION INDIVIDUAL D PARTNERSHIP ]LOCAL-AGENCY O COUNrY-AGENCY (] STATE-AGENCY I] FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS O t GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) 3 FARM 4 PROCESSOR ❑ RESERVATION ❑ ❑ ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: (LAST,�J^TI PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) Cf NIGHTS: NAME(L ,FIR PHONE ITHAREA CODE NIGHTS: NAME(LAST,FIRST) � uq l t ll. PROPERTY OWNS INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING RSTREET ADDRESS ✓ bor bindicala ] INDIVIDUAL I] LOCAL-AGENCY (]STATE.AGENCY CITY ME r EDCORPORATION (] PARTNERSHIP (] COUNTY-AGENCY O FEDERALAGENCY STATE ZIP CO PHONE#W TH AREA CODE Coo � a III. TANK OWNER INFORM N•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREETADDRESS ✓ bor bintlicat# ] INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY ]CORPORATION Q PARTNERSHIP I]COUNTY-AGENCY I] FEDERALAGENCY 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 F4-F4]- V. 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ xx 0indicaW ] 1 SELF-INSURED ]E ANTEE I] 3 INSURANCE [__14 SURETY POND I] 5 LETfEfl OF CREDIT EMPnON L_a.r9!'oTHEfl 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(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILI LOCATONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONIC THIS FORM MUST BE ACCOMPANIED BY.AT EAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) _j5_ / 0C FOROOnA.5 l O ` hq 19