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Q SouR [.S STATE OF CALIFORNIA A ... STATE WATER RESOURCES CONTROL BOARD 3 , UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A � . o° a COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY IV, NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMA ENT ED SITE ONE ITEM 2 INTERIM PERMIT a 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �O I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) Aft DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS n_ / NEAREST C OSS STREET PAR L IONAL} CITY NAME JV v V STATE ZIP CODE SITE PHONE X WITH AREA CODE CAT -oo,"° ✓ BOX TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS F—] 1 GAS STATION Q 2 DISTRIBUTOR RESERVATION OF TANKS AT SITE E.P.A. I.D.#(optional) 0 3 FARM O 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) PHn NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE CO ETE NAME 14 C RE OF ADDRESS INFORMATION la 4 MAILING ORS ADDRESS ✓ box bIndicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY 2 Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NA p STATE ZIP CODE / PHONE#WITH AREA CODE III. TANK OWNER414EQBMATION- MUST BE CO /V NAME OF OWNER CARE OF ADDRESS INFORMATION Q- MAILING OR STREET ADDRESS• ✓ box vindicate Q INDIVIDUAL Q LOCAL-AGENCY [_]STATE-AGENCY CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-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 14J41-L:� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box to indicate 1 SELF-INSURED []2 GUARANTEE Q 3 INSURANCE E] 4 SURETY BOND L� 5 LETTEROFCREDIT Q 6 EXEMPTION = 99 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, CHECK ONE BOX INDICATING WHICH ABOVE 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 APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# _ �_ LLL a 5' LOCATION CODE -OPTIONAL CENSUS TRAC # TIONAL -OPTIONALIyDv '1_ y �1 01 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(12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TAN REGULATIONS FOR0033A R6 i G�