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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD F�s 6—7� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O 1 NEW PERMIT 0 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SI <br /> ONE ITEM O 2 INTERIM PERMIT 0 A AMENDED PERMIT 0 S TEMPORARY SITE CLOSURE <br /> 1. FACILITYISITE INFORMATION&ADDRESS-(MUST BE C LETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTONAL) <br /> GITY NAME STATE CZIP NIDE ;_/1 % SITE PHONE t WITH LA <br /> _ <br /> A <br /> T.1 BOX CORPORATION INDIVIDUAL 0 PARTNERSHIP 0 LOCALAGENCY 0 COUNTVAGENCY' 0 STATE.AGENCY' O FEDERALAOENCY• <br /> DISTRICTS' <br /> N owner d UST Is a public agencY.conplele the following:name of Supervisor of division,section,or office which operates the UST <br /> IF TYPE OF BUSINESS 0 1 GAS STATION 2 DISTRIBUTOR RESERVATION #OF TANKS AT SITE E.P.A. I.D.t(gdlaneq <br /> 0 3 FARM D A PROCESSOR 0 5 OTHER OR TRUST LNJOS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE Is WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE t WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE t WITH AREA CODE NKWTS: NAME(LAST,FIR5T) PHONE It WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET AD ESS V D0abirdQd0 D INDIVIDUAL O LOCAL-AGEWY D STATE-AGENCY <br /> 0 CORPORATION D PARTNERSHIP COUNTY-AGENCY O FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANKOWNER INFORMATION-(MUSTBECOMPLETED) <br /> NAME OF OWNER - NIr1 CARE OF ADDRESS INFORMATION <br /> MAILINGORSTHLLI ESSD /! ✓ Dor birdicau 0 INDIVIDUAL 0 LOCALAGFKCY 0 STATE-AGENCY <br /> CORPORATION 0 PARTNERSWP 0 CWNTYAGENCY 0 FEDEMLAGENCY <br /> CITY NAME STATE ZIP CODE PHON t WITH ARE CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if oAesfions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓Owl binEbaN O I SELF-INSURED O 2 GUARANTEE D 3 INSURANCE O A SURETY BOND <br /> D 5 LETTEROFCREDT 0 6 EXEMPTION O N 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 /> OWNER'S NAME(PRINTED a SIGNED) OWNER'S TITLE DATE MFINFORM:A <br /> LOCAL AGENCY USE ONLY <br /> COUNTY n JURISDICTION x FACILITY tLOCATION CODE -OPTI A .,, 'CENSUS TRACT# - ' �, 9UPVISOR-DISTRICT NALG. Zi VTHIS FORM T BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THS IS A CHANGE OF NLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3'93) OWNER <br />