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� • • eegO°v e c STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ° yo l.. COMPLETE THIS FORM FOR EACH FACILRYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE Y9 7 I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR ILITYNAME ,1[ NAMEOF ATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY AME STATE ZIP DE SITE PHONE#WITH AREA CODE CA ✓ BOX CORPORATION I� INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY E-] COUNrY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY TO INDCATE DISTRICTS O 1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(apliarel) TYPE OF BUSINES ❑ RESERVATION 3 FARM 4 e CESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (P IMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE WITH AREA CODE DAYS: NAME(LAST,FIRST) E NIGHTS: NAME(LAST,FIRST) PHONE# ITHAREACODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA coop II. PROPERTY OWNER INFORMATION• MUST COMPLETED CARE OF ADDRESS INFORMATION NAME MAILING OR STREET ADDRESS ✓ box bindicam INDIVIDUAL O LOCAL-AGENCY 0 BTATE-AGENCY O CORPORATION PARTNERSHIP 0 COUNTY-AGENCYE-1FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPL TED) CARE OF ADDRESS INFORMATION NAME OF OWNER MAILING OR STREET ADDRESS• ✓ box bindicam = INDIVIDUAL LOCAL AGENCY E-71 STATE-AGENCY CORPORATION = PARTNERSHIP 0 COUNTYAGENCY Q FEDERAL-AGENCY CITY NAME - STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOU T NUMBER-Call(91(5)323-9555 if questions arise. TY(TK) HQ L4] ]-EEYJ V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ Eox bindicale L-] I SELF INSURED O 2 GUARANTEE E_1 3 INSURANCE (] 4 SURETY BOND 5 LETrEROFCREDT =6 EXEMPTION =1 99 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.❑ N.❑ U.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR e LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# _33 -L - - — - - LOCATIONCODE -OPTIONAL (CENSUS TRACT# -OPTIONAL SUPVISOR-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(12.91) FILE THIS FO RM WrTH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATION TL#I37 FORao33A Rs �o Nat �.4 ►vu� I9`l3 Sig _3 �"