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- STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A o _ , COMPLETE THIS FORM FOR EACHF�A'CILITY/SITE � to - MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMITK6-u+ANGE OF INFORMATION O 7 PERMANENTLY CL ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1�" 3 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR DRESS ADNEAR ST CROSSSTREETPARCEL#(OPTIONAL) CITY NAME �s STATE DOE � SITE PHONE#WITH AREA CODE �y�)J �(z GGT_. CA I ✓ BOX INCORPORATION E3 INDIVIDU L 0 PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY 0 FEDERAL-AGENCY' TO INDICATE 'NCO DISTRICTS If ownerof UST a a public agency,complete the fulbwing:lame of upeivsor of division,section or office which operates Na UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR = RESEIRFVNNDIAAN #OFTANKS AT SITE E.P.A. I.D.#(optional) ❑ 3 FARM ❑ 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 N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFD) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ INDIVIDUAL Q LOCAL.AGENCY STATE-AGENCY 0 CORPORATION O PARTNERSHIP O COUNTY-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 ✓ borlontlkale D INDIVIDUAL O LOCAL AGENCY STATE-AGENCY CORPORATION O PARTNERSHIP D COUNTY-AGENCY D 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 ✓ cox to N#icata 1 SELF4NSUREO =2 GUARANTEE E--1 3 INSURANCE lj 4 SURETYBOND = 5 LETTEROFCREDR =6 EXEMPTION O 7 STATE FUND O8 STATE FUND&CHIEF FINANCIAL OFFICER LETTERO9STATE FUND&CER TIFICATEOFDEPOSIT =110 LOCAL GOVT MECHANISM 099 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 TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNEWS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY e6 —j 3 COUNTY# JURISDICTION# FACILITY#371`15 1 IL" f5 LOCATION COO -OPTIONAL CENSUS TRACTM -OPTIONAL SUPVISOR-DI ICT CODE -OPTIONAL tO, 3141 6P 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) /D _ / q— n f 4 0