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ig yeC'4 STATE OF CALIFORNIA P `i STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A � : c COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 1 I. FACILITYISITE INFORMATION& ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR V� Lc-n ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME_ STATE ZIP CODE SITE PHONE a WITH AREA CODE 5 CA Box TO INDICATE ©CORPORATION © INDIVIDUAL =PARTNERSHIP []LOCAL-AGENCY Q COUNTY-AGENCY © STATE-AGENCY 0 FEDERAL•AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR ® V IF INDIAN #OF TAXI ITE E.P.A. I.0.#(oprionaiJ RESERVATION O 3 FARM 0 4 PROCESSCR = 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) PPONP 4 VITHP II, PROPERTY OWNER INFORMATION- (MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bindicale © INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY CORPORATION PARTNERSHIP Q COUNTY-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 ✓ box ID indicate ® INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY I1 CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEIDERAL-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 4 4 1013 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ Boz bindicale Q 1 SELF-INSURED Q 2 GUARANTEE Q 0 NSURANCE 6 SURETY BOND 5 LETTER OF CREDIT 6 EXEMPTION I W OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. CHECK ONE BOAC INDICATING WHICH A20VE 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 APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONTHlDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# an NAM- 31 Z�qj LOCATION CODE - TIONAL CENSUS Tj3ACT -0aVONAL SUE5R-DISITRICT CODE -OPTIONAL QF THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) FOR0033A.5