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80UR � STATE OF CALIFORNIA e'e co STATE WATER RESOURCES CONTROL BOARD Wim, UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A d to o o, r�lifoR H� COMPLETE THIS FORM FOR EACH FACILITY/SITE 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 F ILITY NA E NAME OF OPERATOR ADDRESS NEAREST CROSS STREE�L PARCEL#(OP ZONAL) CITY NAME y, STATESI ZIP CODE POO WI H AREA CODE R ✓ BOX Ix CORPORATION INDIVIDUAL 0 PARTNERSHIP Q LOCAL-AGENCY 0 COUNTY-AGENCY Q STATE-E-(AGENCY 0 FEDERAL-AGENCY TO INDICATE DISTRICTS TYPE OF BUSINESS X 1 GAS STATION ❑ 2 DISTRIBUTOR ,/ IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION : 3 FARM = 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) CA a NIGHTS: NAME(LA T,FIRST) J PHONEITH AREA ODE NIGHTS: NAME(LAST,FIRST) PHONE WITH AR A CODF: r � II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bIndicate 0 INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY CORPORATION = PARTNERSHIP COUNTY-AGENCY 0 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 0 INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 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 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box b indicate 1 SELF-INSURED 2 GUARANTEE = 3 INSURANCE 4 SURETY BOND 5 LETTER OF CREDIT 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 8 SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR __7 I ILOCAL AGENCY USE ONLY Pit () COUNTY# JURISDICTION# FACILITY# 3:11 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL s 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(5-91) Q— y FOF=0