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l STATE OF CALIFORNIA ,� '- 's <br /> l'T STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :�� "° <br /> COMPLETE THIS FORM FOR EA FACILITYISITE <br /> MARK ONLY O t NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLtTED) <br /> D FACILITY NAM NAME Of OP ATOR <br /> ADD ESS I NEAREST CROSS STREET PARCEL#(OPFN)NALI <br /> 2 unM Cl < ti 5 1 1DMZ <br /> CITU y)r ckSTATE ZIP CODE SITE PHONE <br /> CAI <br /> TO INDICATE [j]CORPORATION INDIVIDUAL PARTNERSHIP DUC HCTSENCY COUMY-AGENCY O STATEAGENCY FEDEIUL-AGENCY <br /> TYPEOF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR O ✓ IF INDIAN #OFTANY(S AT SITE E.P.A. I.D.S(optional) <br /> Q <br /> RESERVATION / <br /> O 3 FARM 4 PROCESSOR 0 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) PHONE a WITH AREA rnnF <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) #WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> N n CARE OF ADDRESS INFORMATION <br /> ()1>✓kS Yre) ( e_5 <br /> MAI OR STREET ADDRESS ✓ OorblMkaU Q INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION 0 PARTNERSHIP D COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATS I ZIP CODE q 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 ✓ box b Indicate D INDIVIDUAL LOCAL-AGENCY El STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE F E ACCOUNT NUMBER-Call(916 323-9555 if questions arise. <br /> TY(TK) HQ 4 4GQ Y dees�taf haue ® R dog <br /> w� rl naf2' owrL#F �^ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bor bintlkale O 1 SELF-INSURED GUARANTEE 3 INSURANCE 0 4 SURETYBOND <br /> O 5 LETTEROFCREDIT EXEMPTION N 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 ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[] II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED S SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# _ JURISDICTION# FACILITY# <br /> LOCATION DE -OPTIONAL CENSUSTRACT* TQ(VA <br /> TL SUPVISOR-DISTRI TCODE -OPTIONAL <br /> L <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8, LESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(5-911 FOROMM5 <br /> ��` el <br />