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es STATE OF CALIFORNIA J i STATE WATER RESOURCES CONTROL BOARD 3 e,� UNDERGROUND STI ORAGE TANK PERMIT APPLICATION - FORM A n _ . COMPLETE THIS FORM FOR EACH FACILITY/SITE :� e MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OP TOR ezl ADORES I� .� NEAREST CROSS STREET PARCEL PT1ONAL) I CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CA D ✓BOX Q CORPORATION Q INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY 0 COIINTVAGBdCY' Q STATE-AGENCY' 0 FEDERAL-AGENCY' TO INDICATE DISTRICTS Homer of UST&a pubin agency.complete the folIowelg name cf supervaorof dNkion,section oropica O h Mamt a tba UST TYPE OF BUSINESS E:] 1 GAS STATION E::] 2 DISTRIBUTOR I❑ RE EIRVATION INDIAN #OF TANKS AT SITE E.P.A. I.D.p(optional) ❑ 3 FARM O p PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) HONE WITH AREA CODE DAYS: NAME(VAST,FIRST) PHONE#WITH AREA CODE ado 1 - NIGHTS: NAME(LAS ST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMAT1nN-(MUST BE COMPLFTFD) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bczt'In Yo 0INDIVIDUAL C]LOCAL-AGENCY OSTATE-AGENCY Q CORPORATION O PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER K CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS K. ✓ box londicate =1 INDIVIDUAL LOCAL-AGENCY E3 STATE-AGENCY =CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE p WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 44- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓oox tom kale 1 SELF-INSURED L�]2 GUARANTEE 0 3INSURANCE [:j1 SURETY BOND = 5 LETTER OF CREDIT L__16 EXEMPTION L_j T STATE FUND EEI1STATE FUND&CHIEF FINANCIAL OFFICER LETTER 09 STATE FUND&CERTEICATEOFDEPOSIT O10LOCAL GOVT MECHANISM I= 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 ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ II.❑ 111.❑ 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 TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY 4�) 3 COUNTY# JURISDICTION# FACILITY# LOCATION 0 -OPTIONAL CENSUS Ti CT N -1§TL 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 INFOR TI NLYY. OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO TORAGE TANK REGULAITIIOONS I(�'II'i,, FORMA(6-95) � ��