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• • 'LyOV4 STATE OF CALIFORNIA " c 0 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A COMPLETE THIS FORM FOR EACH FACILITYISTTE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C ED ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBAO FACILITY E NAMEO OPERAT R ADDRESS ^fL NEARESTC SSSTREET PARCEL#(OPFIONAL) 1 l CITY NAM e 9TACA ZIP CODE SI'�ONECi �WITH AREA C�7� ✓ WX TIri7"Y-`/^/!—.�CO"RAPORATION INDIVIDUAL Q PARTNERSHIP O �AUAGENCY CO�UNTYAGEEINCY' O STA[TE�-AGENCY' 0 FEDERALAGENCY- TOINDICATE E-1 DISTRICTS' •N owner of UST Is a public agency,mnplere the tcllowing:name of Supervisor of division.section.or office which operates the UST TYPE OF BUSINESS I GAS STATION ❑ 2 DISTRIBUTOR DIV IF INDDIAN a OF TANKS AT SITE E.P.A. I.0.a i0olknal) Q 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 7] NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-MUST OMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ hot to indica, 0 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY O CORPORATION O PARTNERSHIP O COUMYAGENCY O FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER IN . ION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADD S ✓ box b indicate O INDIVIDUAL O LOCAL AGENCY 0 STATE-AGENCY O 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 M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓�xbMkam 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCED A SURELY BON, D 5 LETTER OF CREDIT O 6 EXEMPTION O W 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. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ 11.❑ 111.❑ 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'STfTLE DATE MONTWDAYTYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# t] 7 1 11 LOCATN)NCODE -OPTTONAL CENSUSTRACT# -OPTIONAL SUPVISOR-DISTRICT CODE .OPTIONAL 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 UNDERGROUNDSTORAGE TANK REGULATIONS FORM A(393) FORR7 •