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• • .o - STATE OF CALIFORNIA �`s_ STATE WATER RESOURCES CONTROL BOARD m UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A '°' as �•(oun,.J COMPLETE THIS FORM FOR EACH FACILRYISITE XX MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE �O I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DB AGILITY E NAMEOFOPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY IE STATE ZIP CODE SITE PHONE#WITH AREA CODE CA I/ Box TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR D REV IF INDIAN SERVATION #OF TANKS AT SITE E.P.A. 1.0.#(op#oaal) a 3 FARM Q 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) PHONEE Il. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxb4Mka1# Q INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY ED CORPORATION CI PARTNERSHIP Q COUNrY-AGENCY Q 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 ✓ tax miMkab Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY AGENCY Q 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 44 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓box binEkat# 1 SELF-INSURED QUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q 5 LETTEROFCREDIT 5 EXEMPTION Q 59 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.= IL❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAM E(PR IN TED 6 SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 3:5lU fll S K 3 i/ [1 LOCATION!q�-OPTIONAL CENSUS TRACT# -OPTIOfj�L� SUP)XR- STRICT CODE TIO -OPNAL 2 ?; 5L THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. I FORM A(5-91) FCHOX13A.5 )