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STATE OF CALIFORNIA .•°O'� ' <br /> STATE WATER RESOURCES CONTROL BOARD iy , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FA ITYISITE <br /> MARK ONLY 77 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENT CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT Q d AMENDED PERMIT ❑ # TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS p NEAREST CROSS STREET PARCELIOFTDNAq <br /> CITY NAME STATELP CODE SITE PHONE s WITH AREA CODE <br /> CA <br /> 95,20s11 BOX <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNIY-AGENCY Q STATE AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS t GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN IS OF TANKS AT SITE E.P.A. L D.#(WP00,W) <br /> RESERVATION <br /> Q 3 FARM Q A PROCESSOR IQ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bNbiWiM INDIVIDUAL Q LOCAL-AGENCY Q STATEAGFNCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY,IGENCY Q FEDERAL-AGENCY <br /> CITY NAME 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 ✓ Ooe bVNInHs Q INDIVIDUAL Q LOCALAC#NCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY#BENCY Q FEDERAL#GENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4 4 - 0 3 a a 6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ my biMkate Q 1 SELF-INSURED Q 2 GUARANTEE L-�] 3 INSURANCE Q A SURETY BOND <br /> Q 5 LETTEROFCREDR Q&EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or RI is checked. <br /> CHECKONE BOX INDICATING"ICH ABOVE ADDRESS SHOULD SE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. it. 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) APPLICANTS TIRE DATE MONTHIOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY <br /> LOCATION CODE -OPIIOA4L CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> / d 3 5-0 1 -?d3 leo <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLES THIS ISA CHANGE f SITE INFORMATION ONLY. <br /> FORMA(5-91) <br /> FOR0077A5 <br />