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STATE OF CALIFORNIA V • �' <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> OMPLETE THIS FORM FOR EACH FACILiTYISITE •1• it <br /> MARK ONLY NEW PERMIT 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION iJ ] PERMANENTLY CLOSED ITE ' <br /> ONE ITEM 2 INTERIM PERMIT A AMENDED PERMIT e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA R ACILITYNAMENAME OF OPERATOR <br /> U ' 4- 941'17) PZ <br /> ADD .� NEAREST CROSS STREET PARCELA(OPTIONAL) <br /> CITY NA STATE ZIP E SITE PHONE A WITH AREA CODE <br /> CA <br /> v Box <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL IQ PARTNERSHIP Q LOCAL-AGENCY Q COUNTY AGENCY Q STATE-AGENCY IQ FEDERAL.AGENCY <br /> DISTRITYPE OF BUSINESS I GAS STATION �'i 2 DISTRIBUTOR ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.A(optima) <br /> u L� RESERVATION <br /> Gt 3 FARM A PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ INN om1cm Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CCRPORAnON Q PARTNERSHIP Q CDUNrYAGENCY IQ 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 ✓ tmmmN Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q CoUNrY.AGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO '474 -ZIZ�OFUT <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP ED)—IDENTIFY THE METHOD(S) USED <br /> ✓ �pVdVy U I SELF-INSURED Q 2 geARANTEE 0 3 INSURANCE Q A SURETY BOND <br /> Q 5 LETTER OF CREDIT EVelEXEMPTION Q W 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.= 11.= III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRWTEO A SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JURISDICTION A FACILITY <br /> LOCATION CODE AQP NAL (CENSUS ACH O 7 LD SUPVISOR-DISTRICT DE -OPTIONAL <br /> 11 <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. III <br /> FORM A(5r91) F 5 <br />