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STATEOFCAUFORHIA <br /> 'o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , <br /> COMPLETE THIS FORM FOR EACHFA ILITYISITIE `'��•e�"`" <br /> MARK ONLY D t NEW PERMIT O 3 RENEWAL PERMIT b CHANGE OF INFORMATION 7MANENTLY B D SITE <br /> ONE REM 2 INTERIM PERMIT Q 0 AMENDED PERMIT � 6 TEMPORARY SITE CLOSURE I <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS 1-3 5/v! NEAREST CROSS STREET PARCELA(OPrIONAU <br /> CITU NAME •�'�-F STATE ZIP CODE SITE PHONE i WITH AREA CODE <br /> / CA <br /> TOIN <br /> Box <br /> 0 CORPORATION 0 INDIVIDUAL O PARTN LOCAL-AGENCY ED COUNTYAGENCY' STATE AGENCY' FEDEHALAGENCY' <br /> OSTRICTS' <br /> •N oxrer G UST Is a public agency,corrQl ar d cNisim ion,or office which operates the UST <br /> TYPE OF BUSINESS O 1 GA K)N 0 2 DISTRIBUTO ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.O rcp#orMll <br /> RESERVATION <br /> FARM Q d PROCESSOR THEfl OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NT,FIRST) PHONE#WITH AREA C`DE : NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> S: NAME(LAST.FIR PT40NE#WITWAREACODE NIGHTS: AVE(LAST.FIRST) PHONE#WITH AREA CODE <br /> 11. OPERTY WNER INFORMATION- MUST BE COMPLETED <br /> NAM O N CARE OF ADORE INFORMATION <br /> MAILING OR STREET ADDRESS •T/IT•V' ✓ Ew binElcals E-1 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME Q, <br /> �� STA ZIP E PHONE#WITH AREA CODE <br /> � <br /> III. TANK OWNER INFORMATION- MUST BE COMPLETED <br /> MEIFOWNER 'r YIJ -/f CARE OFADD SS INFORMATION <br /> MAIL GORSTREET ADDRESS ✓ 6tlNaM O INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION = PARTNERSHIP COUNTY-AGENCY = FEDERALAGENCY <br /> CITY NAME STATE I ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ tos 0k1AlG4 1 SELF INSURED 2 GUARANTEE Q 3 INSURANCE O A SURETY BOND <br /> D 5 LETTER OF CREDIT Q 6 EXEMPTION 0 (p OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or Il'ischecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.El II.0 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF OWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY (ri <br /> /' ('�— COUNTY# JURISDICTION# FACILITYN <br /> LOCATION CODE -OP SUS TRACT# -Q°TpNAL 9UPVSOR- TRICT/CODE -Qo710NAt <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE DEFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A ryYS) FORDOMA7 <br /> V <br />