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STATEOFCAUFORWA ��c c+, <br /> STATE WATER RESOURCES CONTROL BOARD .nffi, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISTTE ' ci„o•„-• <br /> MARK ONLY �t NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMITQ <br /> O 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INPWAT19y dT ADDRESS-(MUST BE COMPLETED) <br /> nPA O. NHAE NAME OF OPERAT <br /> ADDR S'$' ENEARESTqROSS*STREE�T PMCELs(OPfKINAyCITY NAME C Z317E PHONE 4 WITH AREA CODE <br /> Box A b <br /> TOINGCATE 0 CORPORATION A INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY O COUNTY-AGENCY• O STATE-AGENCY' <br /> N owner d UST Is a Pcblic agency mnplete the foliowlrlg:name of S DISTRICTS' 0 FEDERAlAf3ENCY <br /> uperv4ar d ENisbn,section.W ofim Which oPeratm the UST <br /> TYPE OF BUSINESS O 1 GAS STATION E�:] 2 DISTRIBUTOR 0 ✓ IF INDIAN a OF TANKS AT SITE E.P.A 1.D.a(col W) <br /> Q 3 FARM 0 4 PROCESSOR 5 OTHER RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(UST,FIRST) PHONE a WITH AREA CODEDAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> ll. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box bin*CmINDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> O CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY 0 FEMIMLAGENCY <br /> CITY NAME STATE ZIP CODE HONE a WITH AREA CODE <br /> D - 75/5 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAIT�STREET ADDRESS ✓ box on'kes INDIVIDUAL O LOCAL-AGENCY D STATE AGENCY <br /> O CORPORATION O PARTNERSHIP O COUNTY-AGENCY D FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓borrbY�CaN 0 1 SELFINSURED 0 2 GUARANTEE E-1 3 INSURANCE I 6ME71IOND <br /> O 5 LEREROFCREDTT 0 5 EXEMPTION X99 OTHER <br /> XP <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: 1. II.O III. <br /> THIS FORM HAS BEEN COMPLETED UND HALT PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> O R'SN�(PRIN D SIGN OWNE TRLE DATE MONTWDAYNEAR <br /> S a z 9G <br /> LOCAL AGENCY USE 61111f Y <br /> COUNTY# JURISDICTION FACILITY# /9'f�..b� <br /> LOCATION CODE -OPTION L CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPT70NAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFO.MATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEME WING THE UNDERGROUNn STORAGE TANK REGULATIONS <br /> FORMA(393) fp70031AAT <br />