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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A r o f0 0 OMPLETE THIS FORM FOR EACH FACILRYISITE MARK ONLY ❑ I NEW PERMIT FV3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAA LITY NAME * ` NAME P BATOR f �m �ln ADD S I /x /YJ, NEAR ST CROSS STREET PARCEL#(OPTIONAL) CITY NAM _ STATEZIP OBDE� SITE PHONE#WITH AREA CODE IL CA 7LJ� v Box TOINdC TE CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUMY-AGENCY 0 STATE-AGENCY Q FEDERAL.AGENCY DISTRICTSTYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN #OF Tri K AT SITE E.P.A. I.D.# l imae ft RESERVATION 0 3 FARM O A 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) NIGHTS: NAME(LAST.FIRST) - PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) D II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESSr/t ✓ bwbindinb D INDIVIDUAL Q LOCAL-AGENCY Q STATE.AGENCY lop CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEDERAL.AGENCt 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 Waq INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCf 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. ES TY(TK) HQ 14F4]-[a p V. PETROLEUM UST FINANCIe RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓hox mind me CVI SELF INSURED 2 GUARANTEE Q 3 INSURANCE Q A SURETY BONG IQ 5 LETTEROFCREDIT Q 6 EXEMPTION Q 99 OTHER VI, LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I OrII• ecked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II. III. i THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH,DAYNEAR LOCAL AGENCY USE ONLY OUNTY# JURISDICTION# FACILITY# CENSUS TRACT# - OPTNALLOCATIONC OPTIONAL QTyO THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THI IS A CHANGE OF SITE INFORMATION ONLY. FORMA(12 9n FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORCQIIFic v