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oo. e <br /> STATE OF CALIFORNIA `°*. <br /> STATE WATER RESOURCES CONTROL BOARD 14 • o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A `� N <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE °a,-°ro�• <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM F7 2 INTERIM PERMIT 0 4 AMENDED PERMIT O S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY - NAMEOFOPERATOR <br /> ADDRESS p - NEAREST CROSS STREET PARCELX(OPTIONAU <br /> CITY NAME STACA ZIP CODE SITE PHONE i WITH AREA CODE <br /> TO INDICATE E! [WVOUAL [:�] PARTNERSHIP Q LOCAL-AGENCY I1 COUNTY-AGENCY D STATE-AGENCY D FEDEIULAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN 19 OF TANKS AT SITE E.P.A. 1.D.#Itpbm f) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: (LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> se {i —c4w d$- vv <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> ✓bol b Ima*aN O INDIVIDUAL =LOCAL-AGENCY O STATE AGENCY <br /> )'u CORPORATION = PARTNERSHIP Q COUNTY.AGENCY FEDERAL AGENCY <br /> CITY NAME ZIP / PHONE#WITH AREA CODE <br /> S� DE - -'qf (C-0 <br /> -V <br /> III. TANK OWNER INFORMATION.(MUST BE COMPLETED) <br /> NAME OF OWNER --yyam� CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING ORSTREET ADDRESS• ImlbhbbaW [__1 INDIVIDUAL O LOCAL-AGENCY I] STATE-AGENCY <br /> CORPORATION L-I PARTNERSHIP Q COUNTYAGENCY E-1 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD 0 EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - QL-[jjZ� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ Eos binObale LI I SELF-INSURED Q 2 GUARANTEE 3 INSURANCE E-1 4 SURETY BONG <br /> O 5 LETrER OF CREDIT E-:]6 EXEMPTION IS OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is ch <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1 ­7 It. 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) APPLICANTSTITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# COUAJ'T (n <br /> 3 6 <br /> LOCATION CODE OPTIONAL CENSUS TRACTi_--OPTIONAL SUPVISOR DISTRICT CODE -OPTIONAL <br /> Sas co L14/ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR00 3A E6 <br />