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't4pUnGf4 C STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD W UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH CIL(TY/SITE MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PER SED S E ONE ITEM 2 INTERIM PERMIT a 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAM P MAILING OR STREET ADDRESS NAME OF OPERATOR ADDRESS�.. CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY 5 J STATE ZIP CODE PHONE # WITH AREA CODE NEARESTC SS STREET PARCEL#(OPTIONAL) n STATE ZIP CODE PHONE # WITH AREA CODE CITY NAME STACEY ZIP COD SITE PHONE # WITH A EA COD � �� I/ BOX TO INDICATE ORPORATION Q INDIVIDUAL Q ARTNERSHIP Q LOCAL -AGENCY Q COUNTY -AGENCY Q STATE -AGENCY Q FEDERAL -AGENCY DISTRICTS TYPE OF BUSINESS a 1 GAS STATION a 2 DISTRIBUTOR0 F INDIAN # OF TANKS AT SITE E. P. A. 1. 0. # (optional) RESE ON Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST IRST) PH N # WITH AREA CODE DAYS: NAME (LAST, FIRST) 1 24� NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE WITH AREA COOP If. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME A _ CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY CORPORATION Q 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 to indicate INDIVIDUAL Q Q LOCAL -AGENCY Q STATE -AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY CITY NAME n STATE ZIP CODE PHONE # WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEt ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. TY (TK) HQ 4 4 - If V. PETROLEUM UST FINANCIA PONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box bindicate 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q 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 or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. E:1 II. 7 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) A , LICANTS TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # FACILITY # A&;1rV,3 =1 [ 1 191 -7131 LOCATION CODE - OPTIONAL CENSUS TRACT # - PT,'ONAL SUPVISOR - DISTRICT CODE - OPTIONAL / THIS FORM MUST BE ACCOMPANIED BY AT LEA6T (1) OR MORE PERMIT APPLICATION - FORM B. UNLESS THIS IS A CHANGE OF E INFORMATION ONLY. w I-UHM A (5-91) FOR0033A-5 G'�