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STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />MARK ONLY L_I 1 NEW PERMIT 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION IJ T PER NENTLY CLOSED �SITE <br />ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br />I. FACILITYISITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />NAME OF OPERATOR <br />// <br />NIGHTS: NAME (LAST. FIRST) <br />CITY NAME <br />PHONC x WITH APCP CMC <br />ADDRESS <br />NEAREST CROSS STREET <br />PARCEL#(OPTIONAL) <br />c T <br />CITY NAME <br />STATE <br />LP CODE <br />SITE PHONE a WITH AREA CODE <br />CA <br />BOX <br />TOO INDICATE CORPORATION Q INDIVIDUAL = PARTNERSHIP LOCALAGENCY COUNTY4GENCY o STATFAGENCY Q FEDERAILAGENCY <br />DSTRCTS <br />TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR <br />O ✓ IF INDIAN <br />Is OF TANKS AT SITE <br />E. P. A. L D. Y (cpf J <br />O 3 FARM O 4 PROCESSOR Q 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST. FIRST) PHONE a WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) PW�P In WITH APCL c <br />NIGHTS: NAME (LAST. FIRST) PHONE a WITH AREA CODE <br />NIGHTS: NAME (LAST. FIRST) <br />CITY NAME <br />PHONC x WITH APCP CMC <br />It PROPFRTY OWNER INFORMATION - (M118T BE ODMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />amb6alMN O POMMAL LOCAL -AGENCY STATE -AGENCY <br />o CORPORATNTI Q PARTIERSNP COUNTYAGENCY Q FEDERAOSENCY <br />CITY NAME <br />I STATE <br />ZIP CODE <br />PHONE a WITH AREA CODE <br />INFORMATION - (MUST BE <br />CARE OF ADDRESS INFORMATION <br />MAILNVG OR STREET ADDRESS ✓ ma a 6aImN = NDMOUAL D LOCAL AGENCY L -D STATE4GENCY <br />ED CORPORATION = PARTNERSMP COUNTY -AGENCY O FMERA14GEWY <br />rnv NAMF I STATE ZIP CODE I PHONE a WITH AREA CODE <br />IV. BOARD OF E90AUZATION UST STORAGE <br />TY (TK) HO 4 0 r} V S� I <br />ACCOUNT NUMBER - Call (916) 323.9555 ti questions arise. <br />V. PETROLEUI F, I. NA L ' ONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ Om bY11im16 CI 1 SELF-INSURED L_-! 2 GUARANTEE `I 3 INSURANCE A SURETY SONO <br />0 5 LETTER OF CREDIT 0 6 EXEMPTION m OTHER <br />VL LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is Checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L = I. = III. <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANTS NAME (PRINTED & SIGNATURE) APPLDANTS TITLE DATE MONTHIDAY/YEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY a JURISDICTION a FACILITY a G%P &eA& v <br />LOCATION CODE - OPTIONAL CENSUS TRACTa- OPTIONAL ISUPVISOR- DISTRICT CODE- 9PTXWX <br />0/ I a 3S- _ 1 3 a 3 II I I(.(Yz Cz� <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br />