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STATE OF CALIFORNIA c'; STATE WATER RESOURCES CONTROL BOARD T e,� m UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A 5 - , COMPLETE THIS FORM FOR EACH FACILITY/SITE m �o MARK ONLY ❑ o NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �3 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR NEAREST CROSS STREET PARCEL#(OPTIONAL) ADDRESS2 CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CA ✓BOX CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY' 0 STATE-AGENCY' O FEDERAL-AGENCY' TO INDICATE DISTRICTS 9 ormeral USTb a public agetwy,complete the lolbWOT name of sitPernsord division,section or office which operates the UST TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR ❑ RESEIF INDIAN x OF TANKS AT SITE E.P.A. I.D.#(optional) O 3 FARM Q 4 PROCESSOR O 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) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE It. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFD) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bcxton:raa O INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY 0 CORPORATION 0 PARTNERSHIP D 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 ✓ boxtoMicate 0 INDMDUAL 0 LOGAL-AGENCY D STATE-AGENCY 0 CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HO V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate O I SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND a 5 LETTEROFCREOR O 6 EXEMPTION 0 7 STATE FUND O8STATEFUND&CHIEF FINANCIALOFFICER LETTER 09 STATE FUND&CERTIFICATE OF DEPOSIT OtoLOCAL GOVT.MECHANISM 099 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.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S nTLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION N FACILITY 7 m LOCATION CODE -OPTIONAL CEN SUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL ^ / OV THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SH INFORMATION ONLY. OWNER MUST FILE THIS FORM VWHE LOCAL AGENCY IMPLEMENTING THE UNDERGROUi TANK REGULATIONS FORMA(6-95)