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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS tfREET PARCEL # (OPTIONAL) NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODh STATE CITY NAME STATE ZIP CODE SITE PHONE # WITH AREA CODE R5<4'L 6A1 CA a ✓ BOX 0 CORPORATION INDIVIDUAL 0 PARTNERSHIP O LOCAL -AGENCY 000UNTY-AGENCY' STATE -AGENCY' FEDERAL -AGENCY' TO INDICATE DISTRICTS ' 8 owner of UST is a public agency, complete the folbwing: name of supervisor of division, section or office which operates the UST TYPE OF BUSINESS ' 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN # OF TANKS AT SITE E. P. A. I. D. # (optional) �J RESERVATIONg 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 MA(LING dIR STREET-ADIDAPESS DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODh STATE NI HTS: NAME (LAST, FIRS PHONE # WI'M AREA CODE // 6,94 Z �G.... 2- I II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MA(LING dIR STREET-ADIDAPESS ✓ box to indicate -INDIVIDUAL LOCAL -AGENCY STATE -AGENCY M%f>/ LING OR STREtT ADDRESS = CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY FEDERAL -AGENCY CITY STATE ZIP CODE PHONE # WITH AREA CODE // 6,94 Z �G.... 2- I III. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION M%f>/ LING OR STREtT ADDRESS ✓ box to indicate INDIVIDUAL LOCAL -AGENCY a STATE -AGENCY 0 CORPORATION RTNERSHIP 0 COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STATE ZIP CODEPHONE# WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. ' TY (TK) j4-- F4]4- -1012 V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box to indicate 0 1 SELF-INSURED = 2 GUARANTEE = 3 INSURANCE = 4 SURETY BOND = 5 LETTER OF CREDIT = 6 EXEMPTION 7 STATE FUND 0 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. If. O III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, 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 #44 m FTTI El 1) 1 i ]'P LOCATION CODE - OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL THIS FORM MUST BE ACCOMPANIED BY if LEAST (1) R PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMWTI N ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMA (6-95)