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it STATE OFCAUFORNA c ii STATE WATER RESOURCES CONTROL BOARD 3 UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A „ n COMPLETE THIS FORM FOR EACHFACILITYISITE MARK ONLY t NEW PERMIT Q 3 RENEWAL PERMIT 5R^6 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q a TEMPORARY SITE CLOSURE I. FACILfTY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR 7 ADDRESS NEAREST dR0§5§TREET PARCELCOPTIONALJ i CITY N M C. sTArE ZIP CODE SITE PHONE#WITH AREA CODE CA - 43 a TO O CORPORATION O INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY Q COUNTYAGENCY' O STATE-AGENCY' FEDERAL-AGENCY' DISTRICTS' H owner of UST Is a public agency,complete the folImIng:name Su minor of division,section,or office which operates the UST TYPE OF BUSINESS O t GAS STATION 0 2 DISTRIBUTOR RE-/ IFINDIAN SERVATION #OFTANKSATSITE E.P.A. I.D.s(opfional) 0 3 FARM O 4 PROCESSOR Q 6 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED NAMECARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓boa lo Indicate INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY O CORPORATION PARTNERSHIP COUNTY-AGENCY LD 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 ✓ boa bindiate INDIVIDUAL LOCAL-AGENCY O STATE AGENCY CORPORATION Q PARTNERSHIP O COUNTYAGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. TY(TK) HQ F4174- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓boa bindicaN (]t SELF-INSURED 2 GUARANTEE 3 INSURANCE O 4 SURETY BOND D 5 LETTER OF CREDIT Q 5 EXEMPTION Q 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: 1.E] II.= III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUmNTY# JURISDICTION FAcuro �J LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE •OPTpNAL ZL /5 7 THIS FORM MUST BE ACCOMPANIED BY AT L A (1)OR MORE PERMrr APPUCATION• FORM B,UNLESS THIS 1S A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(393) L FORDOM.R7