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e*'Ounccs STATE OF CALIFORNIA Ara cO 1 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE t� ' MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR i CA Z'/�= ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 3a evs--� CITY NAME 4 STATER ZIP CODE PHO #WITH AREA CODE f CA -- j., ✓BOX Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' TO INDICATE DISTRICTS If owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION Q 3 FARM 0 4 PROCESSOR 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 CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE CO"PLFTFD) NAME CARE OF ADDRESS INFORMATION �—%E' G4G- ��j/ '4 MAILING OR STREET ADDRESS ✓ bcx to i:w'a Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY -j>, '0 D Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME fSTAT ZIP CODE PHONE#WITH AREA CODE rC-r� 9� ;7Z> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION (z-%'� MAILING OR STREET ADDRESS ✓ boxto 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 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 ✓box to indicate Q 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 7 STATE FUND Q 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 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.❑ it.a III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJUR`,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# �--� ❑ f LOCATION CODE -OPTIONAL CENSUS TRACT# -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. FORMA(6-95) OWNER MUST FILE THIS FORW THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO*TORAGE TANK REGULATIONS