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Pp'S�UR [ Co STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3 , UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �j Ci L,r V hN // COMPLETE THIS FORM FOR EACH FACILrrY/SITE MARK ONLY '1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E:] 7 PERMANENTLY CLOSED SITE ONE ITEM ��/❑`"`2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ` I. FACILITY/SITE INFORMATIQN&ADD SS-(MUST BE COMPLETED) DRA OR FACILITY NAM NAME OF OPERATOR ADDRES NEAREST CROSS STREET PARCEL N(OPTIONAL) CITY NAM STATE ZIP CODE SITE PHONE#WITH AREA CODE CA ✓ BOX CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY TO INDICATE DISTRICTS TYPE OF BUSINESS E:] 1 GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE F.P.A. I.D.#(aptronat) RESERVATION leels:> v 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS Ott EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA-CODE_ NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II, PROPERTY OWNER INFOR ATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box ID indicate ] INDIVIDUAL ® LOCAL-AGENCY 0 STATE-AGENCY Q CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-( ST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to Indicate a INDIVIDUAL 0 LOCAL-AGENCY [771STATE-AGENCY 0 CORPORATION 0 PARTNERSHIP ] COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 1 IV. BOARD OF EQUALIZATION UST STORM FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 14 14 - 1h 1 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bindicate 0 1 SELF-INSURED 0 2 GUARANTEE Q 3 INSURANCE 0 4 SURETY BOND O 5 LETTEROFCRECIT 1 0 6 EXEMPTION 0 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: L❑ 11.E—] III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY , �- COUNTY# JURISDICTION# FACILITY# YO g LOCATION CODE -OP i 10NAL CENSUS TRACT# - NAL SUPVISOR-DISTRICT CODE -OPTIONAL 6P O THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SrrE INFORMATIO"NLY. FORM A(5-91) ' :�OR9G33A-S