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ea 4 t STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 'o / UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A V tyi 4nonWn COMPLETE THIS FORM FOR EACH FACILRY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E946 CHANGE OF INFORMATION ❑ 7 PEAR_ yMAANFNTLY CLOSED SITE 7 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ✓{��—tI I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA OR FACILITY NAME — NAME OF OPERATOR C.tt ADDRESS ; NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME 7 STATE ZIP CODE I SITE PHONE#WITH AREA CODE ✓ BOX 6 Y061t�d"35; 7 O TO INDICATE O CORPORATION 0 INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY 0 COUNrYAGENCY STATE-AGENCY 0 FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR / IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(optimall ❑ RESERVATION Q 3 FARM O 4 PROCESSOR Q 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) II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box 0Ird,=i 0 INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY O CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OW NER CARE OF ADORESS INFORMATION MAILING OR STREET ADDRESS ✓ Dox 0iMicale 0 INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY CORPORATION = PARTNERSHIP I= COUNTY-AGENCY 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 0Wicale I SELF-INSURED I� UARANTEE = 31NSURANCE O A SURETY BONG O 5 LERER OF CREDIT 6 EXEMPTION Nigg OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or 11 is checked. CHECKONE 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 APP LI CANTS NAME(P R INTED&S IGNATU RE) APPLICANTS TITLE DATE MONTHUOAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# ^7 M6g47-1-Z '" LOCA TION CODE -OPT/ONAL CENSUS TRACT# -OPTIONAL I SUPVI50R-DISTRICT CODE -OPT/ONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANG OF S INFORMATION ONLY. � FORM A(S91) FOR00330