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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i '0 i I UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY D SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE , C, d- 1. FACILITY/SITE INFORMATION III ADDRESS-(MUST BE COMPLETED) / v CBA OR FACILITY NAME +NEARESTCRO ME OF OPERATOR ADDRESS - -� 1 STREET c PARCELN(OPFpnpq CLTY NAME I STATE ZIPC DE Q SITE PHONE Box N WITH AREA CODE CA L ✓ TO INDICATE O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTYdGENCY' 0 STATE-AGENCY' FEDERAL#GENCY' N owner of UST Is a pobdc agency, S DISTRICTS' mmplela the following: of Su rvbor of tlMisbn,eeMbn,W coke which operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IFINDIAN NOFTANKSATSITE E.P.A. I.D.9(cpnnae ❑ 3 FARM Q 4 PROCESSOR OTHER — 5 RESERVATION OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WIT AREA CODE DAYS: NAME(LAST,FIRST) ti 877 . PHONE a WITH AREA CODE ; _ NIGHTS: NAME(LAST,FIRSTj PHONE#WIT AREA CODE NIGHTS: NAME(LAST,FIRST) PHONEi WITH AR EA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET—ADDRESS ✓ boxbintlbN 0 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY __ 0 CORPORATION 0 PARTNERSWP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bon bindbbs O INDIVIDUAL 0 LOCAL AGENCY O STATE-AGENCY O CORPORATION 0 PARTNERSHIP O GOUKIY AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓bon b Indicate 0 1 SELFINSURED 0 2 GUARANTEE 0 3 INSURANCE 0 5 LETTEROFCREDIT O e ExEMPTION %OTHER 0 1 SURETYBOND 0 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 INDICATINGWHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= It.[::] III.0 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED S SIGNED) OWNER'S TITLE DATE MONTH/DAY/VEAR l LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTIO� CENSUS TRACTN -OPTIONAL 9UFNISOR•D19TflICT CODE -pp� 1� THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORMA(3g3) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS • 6 FORDDS31Ht7