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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILRYISITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT [1] 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE -52— I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA FAC ILI N AME APAMENAME OF OPERATOR ADM06— - �_ j- NEAREST CROSS STREE PARCEL#(OPfIONAQ CITY C//Y✓' c��/�r STA ZI DE 1 SITE PHONE#WITH AREA CODE CA I/ BOX TO INDICATE D CORPORATION O INDIVIDUAL 0 PARTNERSHIP 0 LOCAL AGENCY COUNrY.AGENCY D STATE-AGENCY E-1 FEDERAL AGENCY DISTRICTS TYPE OF BUSINESS [=] 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TA KS AT SITE E.P.A. I.D.#(optional) RESERVATION O 3 FARM O 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) NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ Dox mirdkme [7:) INDIVIDUAL O LOCAL AGENCY DSTATE-AGENCY CORPORATION L-j PARTNERSHIP I1 COUNTY-AGENCY D FEDERAL-AGENCY CITY NAME STATE 21P CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS• ✓ box b Indicate Q INDIVIDUAL 0 LOCAL AGENCY (71 STATE AGENCY O CORPORATION = PARTNERSHIP = COUNTYAGENCY (] 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) HO ��4]- Z Z V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECOMP ED)—IDENTIFYTHEMETHOD(S) USED ✓ box w indicate n �I SELF INSURED 2 ARANTEE (]31NSURANCE E=14 SURETY BOND LJ 5 LETTEROFCREDIT EXEMPTION A 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.❑ U. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAVNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# !,L `39i pkrerss I��Ll5r- LOCATION CODE -QRjIOI'{AL CENSUS TRACT#APjJ%pNA� a V ISO SUP v R- TRICT CODE -OPTIONAL V I G THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION O�L FORM A(I2-91) FILE THIS FORM WITH AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK R TIONS RD � x /