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RATE OF CAUFOISEA <br /> $TATE WATER RESOURCES CONTROL BOARD <br /> y UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE & <br /> MARK ONLY t NEW PERMIT O 3 RENEWAL PERMIT O S CHANGE OF INFORMATION Q 7 PERMANENTLY CL <br /> ONE REM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE s <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME ` f �T NAMEOFOPERATOR <br /> �` I.FN <br /> 05 11S 40r <br /> ADDRESS NEAREST CROSS STREET PARCELaIOPrpNAU <br /> asic� � rnf9 <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> CA <br /> TO INDICATE CORPORATION O INDIVIDUAL O PARTNERSHP LOCAL•AGENCY O COUNTY-AGENCY' STATE-AGENCY' 0 FEDERAL AGENCY' <br /> DISTRICTS' <br /> 'N owner of UST Is a public agency.wnplete the folio":name of Supervisor of divabn,section,or office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN s OF TANKS AT SITE E.P.A. I.D.0 Icpaweg <br /> 3 FARM 4 PROCESSOR 6 OTHER RESERVATION <br /> O O OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA OODENIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME 11 CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS (( ✓ bovbbaMb INDIVIDUAL (1 LOCAL-AGENCY ED STATE-AGENCY <br /> CORPORATIONO PARTNERSINP =COUNTY#GENCY FEDERAL-AGENCY <br /> CITY NAMES kAT,n STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ borbVebwa = INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> O CORPORATION I71 PARTNERSHP O COUNTYAGENCY Q FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ [4T4--]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓be Is Mims 0 1 SELF-INSURED O 2 GUARANTEE ED 3 INSURANCE O s SURETYBONO <br /> 5 LETTEROFCREDIT =6 EXEMPTION 0 IS OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notilication and billing will be sent to the tank owner unless box I or 11checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.O IN. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED 6 SIGNED) OWNERS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY Y JURISDICTION a FACILITY a <br /> ® lal 31 110 �1 F11 <br /> LOCATION CODE -OPT CENSUS TRACTa •OPTIONAL 9UPVLROR-DISTRICT CODE -OPTpAIAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFOR }� NLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULA <br /> FORMA(3/93) s � �' SART <br /> 510.1 q 4 �RRVI <br />