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• STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A Ue C�LIF°e M•n COMPLETETHIS FORM FOR EACH FACILITYISITE MARK ONLY F-1 i NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE - I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DB#7 FACIL17 NAME NAME OF OPERATOR W AODR SS / NEAREST CROSS STREET PMCEL#IOPTgNAq m D r CITY STATEZIPC E SITE PHONE AREA CODE y� CA TO INDICATE O CORPORATION 0 INDIVIDUAL Q PARTNERSHIP DLOCALA ENCY COUNTY AGENCY O STATE AGENCY O FEDERALAGENCY TYPE OF BUSINESS 0 1 GAS STATION 2 DISTRIBUTOR 0 gESEF IND IAN ON #OF TANKS SITE E.P.A. I.D.#(optional) O 3 FARM Q 4 PROCESSORAT 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (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) WITH AREA COOP II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓boxbindicate INDIVIDUAL O LOCAL-AGENCY 71 STATE-AGENCY l�CORPORATION D PARTNERSHIP D COUNTY-AGENCY = 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 m Indicate INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY l�CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY D FEDERAL-AGENCY 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 4 4 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box 0indicale SELF INSURED 2 GUARANTEE 0 3 INSURANCE O 1 SURETY BONG 5 LETTEROFCREDIT 6 EXEMPTION 93 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.O III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAM E(PR IN TED B S IGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY It n -7v � seve✓ I/ � LOCATION CODE/OPTIONAL CENSUS TRACT OPTION)ISUPVISOR-DISTRICT CODE -OPTIONAL 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) FOR0033A-5