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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> )I l� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e oe <br /> COMPLETE THIS FORM FOR EACH FACtLITYISITE <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY N ME a pa# lj�j NAME OF OPERATOR <br /> W(/ v l l <br /> ADDRE SN AREST CROSS STRFWT PARCEL 0(OPTIONAL) <br /> i <br /> CITY STATEDE ZIP SITE PHONE Al WITH AREA CODE r. <br /> CA aos <br /> ✓ Box <br /> TO INDICATE F-1 CORPORATION 0 INDIVIDUAL I:�]PARTNERSHIP O LOCAL AGENCY E-1 COUNTYAGENCY STATE-AGENCY D FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O I GAS STATION = 2 DISTRIBUTOR O RESERVATION <br /> IF INDIAN <br /> DDION #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> O 3 FARM O 4 PROCESSOR 5 OTHER Ofl TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE WITH AREA CPOE DAYS: NAME(LAST.FIRST) <br /> NIGHTS: NAME(LAST.FIRS PHONE#WTTH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> % PHONE f WITH AREA CODE <br /> II. PROPERTY OVINE NFORMATION- MUST BE COMPLETED <br /> NAME CARE OF IN,RESS INFORMATION <br /> MAILING OR STREET ADDRESS I/box b ININate INDIVIDUAL LOCAL-AGENCY STATE AGENCY <br /> CORPORATION PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP GO PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION- UST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATI <br /> MAILING OR STREET ADDRESS ✓ boa bindcaU [=1 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> (]CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE%EACCOUNT NUMBER-Call(916)323-9555 g questions %USE TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILST BE COMPLETED)—IDENTIFY THE METHOD(S) <br /> ✓ boa IOIMkala 1 SEURNSURED [=1 2 GUARANTEE O 3 INSURANCE O a SURETY 80ND <br /> D 5 LETrEROFCREDIT xt 6 EXEMPTION 0 99 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.[�] 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 /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY g <br /> COUNTY# JURISDICTION# FACILITY# <br /> 1--1 A <br /> LOCATION CODE -OPTIONAL CENSUSTRACT# -OP NA SUPVISOR-DISTRICT CODE -OP TIONAL <br /> THIS FOR M T BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> AA6 <br />