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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY (] NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS <br /> ONE REM 2 INTERIM PERMIT 6 AMENDED PERMIT Eja TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DB FACILIJA'NAM /] NAM OPERATOR <br /> 45 0 <br /> ADD R i NEAREST CROSS STREET MCEL I(OPIONAL) <br /> CI NA STATE SITE PHONE t WITH AREA CODE <br /> CA L <br /> TOINMATE 0 CORPORATION D INDIVIDUAL O PARTNERSHIP I] LOCALAGENCY 0 COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTORD RESERVATION <br /> / IF INDIAN <br /> N OF TAN I$$AT SITE E.P.A. I.D.#ropli aq <br /> 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS 8 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE*WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA COQF <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindwG Ell INDIVIDUAL 11 LOCAL-AGENCY [-I STATE.AGENCY <br /> Q CORPORATION O PARTNERSHIP D COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS• ✓ box bintlbale INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION D PARTNERSHIP L--1 COUNTY-AGENCY D FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION <br /> IOJLIST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4-P4 -Is'L't1-1-'.✓.'v_iu <br /> V. PETROLEUM UST FINANC L RESPONSIBILITY-(MUST BEC PLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bintlicala i SELF-INSURED 2 GUARAMEE 0 3 INSURANCE Q 4 SURETY BOND <br /> 5 LETTEROFCREDIT E:]6 EXEMPTION Ie OTHER <br /> VI. 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: I.0 II.❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDI IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PR IN TED&S IGNATU RE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# � 1 ,a JURISDICTION# FACILITY# <br /> LOCATION CODE IT4LCENSUS Tg/�,aTOP T/0 SUPVISO - !L <br /> CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY, <br /> FORM Anz-Bn FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0033A F6 <br />