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C <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD t` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W m� <br /> y; . <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY F-1 t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM L-12 INTERIM PERMIT 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE <br /> fikl <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DB FACILITY NA NAMEOFOPERATOR <br /> Ort'a l I- ro5 <br /> ADDR�� NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NA STATEZIP CODE SITE PHONE%WITH AREA CODE <br /> CA <br /> BOX <br /> TO INDICATE O CORPORATION (]INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY 0 COUNTYAGENCY O STATE-AGENCY (] FEDERAL-AGENCY <br /> FI <br /> TYPE OF BUSINESS = t GAS STATION i= 2 DISTRIBUTOR FISERVATION #OF T.ANISITE E.P.A. I.D.#(optional) <br /> 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) Copp <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS bmwlMka = INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> 0 CORPORATION = PARTNERSWP O COUNTY-AGENCY 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 ✓ bol t MOW E] INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> (]CORPORATION 0 PARTNERSHIP 0 COUNTY AGENCY 0 FEDERAL AGENCY <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) HQ F4_41- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COM LETED)—IDENTIFY THE METHODS) USED <br /> ✓ borblMicale 1 SELF-INSURED 0 YGUARANTEE 17-1 3 INSURANCE i�4 SURETY BOND <br /> D 5 LETTER OF CREDIT OV6 EXEMPTION 0 IN 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.O II.L�] III.O <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 TITLE DATE MONTWDAWYEAfl <br /> LOCAL AGENCY USE ONLY q <br /> COUNTY# JURISDICTION# FACILITY# <br /> 2H 01-78 i5 �ti iD�a1 <br /> LOCATION CODES TONAL CENSUS WCTT0 OPTIONAL SUPVISOR`DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(11))OR MORE PERMIT APPLICATION•-FFORRM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A("l) FOR0033A <br /> �1 <br /> 1 <br />