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e Y STATE OF CALIFORNIA ,' 6c'., STATE WATER RESOURCES CONTROL BOARD .e,� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :w _ , . COMPLETE THIS FORM FOR EACH FACILITY/SITE :� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DB R FACILITY NAME NA OF OPERATOR r P �roe ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME,.U'Y/p STATE ZIP CODE SITE PHONEN WITH AREA CODE o CA ✓BOXCORPORATION O INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' TO INDICATETt DISTRICTS Hovmerd USTis a pubrCa9eM.,. Wte91e101Mwm9:named sgxremord ciNeW,section or ofE,wha opemles the UST DISTRIBUTOR ❑I TION 2 DS ✓IF INDIAN a OF TANKS AT SITE TYPE OF BUSINESS 1 GAS STA ❑ RESERVATION 3 FARM Q 4 PROCESSOR ❑ 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) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREETADDRESS ✓ boxlo^date Q INDIVIDUAL lF1 LOCAL-AGENCY O STATE-AGENCY 0 CORPORATION O PARTNERSHIP ] COUNIY.AGENCY O 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 ✓ boxtoindcale =INDIVIDUAL DLOCAL-AGENCY E3 STATE-AGENCY l=CORPORATION 0 PARTNERSHIP D COUMV-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ 4 4- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to in0icele I SELF-INSURED = 2 GUARANTEE = 31NSURANCE El 4 SURETY BOND 0 5 LETTEROFCREDR =6 EXEMPTION =7 STATE FUND []6 STATE RIND&CHIEF FINANCIAL OFFICER LETTER O 9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O 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.❑ II.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER-STTLE I DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY PR a:513 0 Lk COUNTY# JURISDICTION7SUPVISOR ODFACILITY# m [m D 6 LOCATIONCOAC DE -OPTIONAL CENSUS TRTp -OPTIONALp� -DISTRICT CE -OPT NAL © s v THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(6-95) 3-�a�i91f^/