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i y rR6O�R C cfi STATE OF CALIFORNIA r STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT I<5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED S ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT a❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) DBAOR FACILITY NAMENAME OF OPERATOR r it t ADDRESS NEARES CROSS STREET PARCEL#(OPTIONAL) 69 CITY NA E STATE ZIP CODE SITE PHONE#WITH AREA CODE CA 917D7 ✓ Box TO INDICATECORPORATION INDIVIDUAL PARTNERSHIP ® LOCAL-AGENCY 0 COUNTY-AGENCY I= STATE-AGENCY FEDERALAGENCY r DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(opllona)} RESERVATION 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRI ARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#1TH AREA CODE DAYS: NAME(LAST,FIRST) CINE_#YILITF!AREA CQDF NIGHTS: NAME(LAST,FIRST) PHONE#WIT AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE;WITH AREA COIN: II. PROPERTY OWNER INFORMATION- MUST BEC PLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bindicate 0 INDIVIDUAL 0 LOCAL-AGENCY ® STATE-AGENCY CORPORATION PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY CITY 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 ✓ box to Indicate 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY 0 CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME TATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBtR-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box io indltate 0 1 SELF-INSURED ®2 GUARANTEE 3 INSURANCE [] d SURETY BOND 5 LETTER OF CREDIT ©6 EXEMPTION 99 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.❑ IL❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 39 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL- SUPVISOR-DISTRICT C,T�IDE -OPTIONAL tj�'4 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- M B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) � � �� —j-� �FOROR73A,