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• 0 .JVnC STATE OF CALIFORNIA �, STATE WATER RESOURCES CONTROL BOARD 4.. "� o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A � os N: . 4�t,-4n Y,n COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION EV7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA FACILITY NAME L NAMEOFOPERATOR ADD ly NEAREST CROSS STREET PMCELN(OPIONAL) CITY N STAcaTE ZIP CODE SITE PHONE#WITH AREA CODE Box r TOINDICATE a CORPORATION 0 INDIVIDUAL O PARTNERSHIP C__1 LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERALAGENCY DISTRICTS TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR O ✓ IF INDIAN #OFT AT SITE E.P.A. I.D.p(optianap RESERVATION Q 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE u WITH AREA CODE NIGHTS: NAME(LAST,FIRST) IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bintliata INDIVIDUAL 0 LCCALAGENCY 0 STATEAGENCY CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY i= FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box binbkalb Q INDIVIDUAL Q LOCAL-AGENCY D STATE AGENCY 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDEMLAGENCY CITY NAME STATE ZIP CODE PHONE x WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ F4-[-4]- V. 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE CO ETED)—IDENTIFY THE METHOD(S) USED ✓ box 01Mkate O 1 SELFINSURED0 GUARANTEE 0 31NSURANCE 0 4 SURETY BOND D 5 LETTEROFCREDIT 5 EXEMPTION O BB 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 ABCVE 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) APPLICANT'S TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY# 1044-4 JURISDICTION# FACILITY# LOCATION col- PTIONAL CENSI$TRACT# -OPL SUPV(SOR-OISTRICTCODE -OTIONALM • ZnO n 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) FOi10077A5