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s' • OJR [9 STATE OF CALIFORNIA �e«l.�..• o0 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A Div -,LA'JI✓ COMPLETE THIS FORM FOR EACH FACILRYISITE NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION n T PERMANENTLY CLOSED SITE MARK ONLY [ 1 99 ONE ITEM CSI 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE / I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) ORFACI NA E j _ NA OFOPERATOR ADDR§5 N A/BEST CROSS STREET PARCEL#(OPTIONAL) In4nL 6 � - CITY N E STATE ZIP OOE RITE PHONE ITH ARE=COpE� BOX TO INDICATE D CORPORATION INDIVIDUAL O PARTNERSHIP [_1 LOCAL-AGENCY 0 COURTYAGENCY D STATE-AGENCY E:1 FEDERAL AGENCY DISTRICTS TYPE OF BUSINESS O t GAS STATION 2 DISTRIBUTOR E—] RESEIRF INDIAN VATTION #OF TANIjS AT SITE E.P.A. I.D.x(optional) 3 FARM 4 PROCESSOR Q 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 COD NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREETAODRESS ✓ box to indx:ate L�l INDIVIDUAL L�] LOCAL-AGENCY IJ STATE AGENCY E::]CORPORATION = PARTNERSHIP COUNTY-AGENCY = 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 biMkax, INDIVIDUAL LOCAL-AGENCY LD STATE AGENCY O CORPORATION PARTNERSHIP COUNTY AGENCY FEDERAL-AGENCY CITY NAME - STATE ZIP CODE PHONE x WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY TK) HO 4141- 0 2 2 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPOED)—IDENTIFY THE METHOD(S) USED ✓ box Minbinle E::] I SELF INSURED 2 ARANTEE U 3 INSURANCE 4 SURETY BONG 5 LETTER OF CREDIT EXEMPTION 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is checked. CHECK ONE 80X INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED B SIGNATURE( APPLICANTS TITLE DATE MONTHIDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION It ACILITY# ^� 3.19 l-RI,uCP. \� �� e) � •(i`J LOGATIO -OPTIONAL CENSUS TRACT# - TIO AL SUPVISO -DISI TCODE -OP THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. vORM A 02.91) FILE THIS FORM WITH THE LOCAL AGENCY IMP E NTING THE UNDERGROUND STORAGE TANK REGULATIONS ` FOfl00770.R6 is �t13