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'o/ 1W eeoew e <br /> STATE OF CALIFORNIA o i� <br /> STATE WATER RESOURCES CONTROL BOARD 3y <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� Y <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY EV1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE , <br /> ONE ITEM El 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> F <br /> f;Znl" <br /> ILITY NAME NAMEOFOPERATOR <br /> U �_ <br /> NEAREST CROSS STREET PARCELp(OPTIONAL) <br /> CITY NAfjE STATE ZIP C E SITE PHONE N WITH AREA CODE <br /> CA <br /> ✓ Box <br /> TOINDICATE CORPORATION E-1 INDIVIDUAL 0 PARTNERSHIP =1 LOCAL-AGENCY COUNTY AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> DSTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION = 2 DISTRIBUTOR 0 / IF INDIAN RESERVATION #OF TANKS AT SITE E P.A. I.D.#Ia fimal) <br /> O 3 FARM O 4 PROCESSOR = 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) PHONE I WITH AREA COQF_ <br /> ll. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box 0 0 INDIVIDUAL Q LOCA AAGENCY O STATE-AGENCY <br /> CORPORATION E-1 PARTNERSHIP 0 COUNTY-AGENCY 0 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 0 Q INDIVIDUAL Q LOCAL-AGENCY Q STATEAGENCY <br /> O CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE IF WITH AREA CODE <br /> IV, BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP ED)—IDENTIFY THE METHODS) USED <br /> ✓ WX 0imicale D 1 SELF INSURED = 2 gfmAI 0 3 INSURANCE 0 4 SUR7ND <br /> D 5 LETTFROFCREDIT EXEMPTION O 93 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.0 II.O III.O <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(PRINTED&SIGNATURE) APPUCANPS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE - ZONAL CENSUS TRACT# -OPT/O L SUPVISOR-DISTRICTC DE -OPTIONAL <br /> 2 3 D3 Z <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 /> FORMA(5-91) FOgpp3� <br /> i � , <br />