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,iaVA <br /> '- STATE OF CAUFORWA ' <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD W.:q$ y: <br /> N, �� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A `•, � <br /> jCOMPLETE THIS FORM FOR EACH FACILITYISITIE `'t�•P""'� <br /> MARK ONLY O I NEW PERMIT O 3 RENEWAL PERMIT F-1 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT Q a AMENDED PERMIT 4Nq S TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION 6 ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILI NAME / NAMEOFOPERATOR <br /> Gr G o%Y r <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPrIONMt) <br /> Z . GAS �' •-. <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> O T CA <br /> TO DICATE �CORPORATION 0 INDIVIDUAL D PARTNERSHIP E-1LOCAL-AGENCY Q CWMY-AGENCY' Q STATE-AGENCY' FEDERAL#GENCV' <br /> DISTRICTS' <br /> •H amer of UST Is a pudic agency,Pooplate the following:name d Supervisor of division,section,a Price which operates the UST <br /> TYPE OF BUSINESS 0 f GAS STATION 0 2 DISTRIBUTOR [�::I <br /> RESERVATION <br /> IF INDIAN <br /> 10N s OF TANKS AT SITE E.P.A. I.D.a(opfionel) <br /> 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS 1 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,F STI PHON WITH AREA CODE DAYS:NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> io _423 <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE%WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR&REETADDRESS <br /> -Y�� ✓Eos btrdhaN INDIVIDUAL [:1 LOCAL-AGENCY ED STATE-AGENCY <br /> ZJCTa` O CORPORATION PARTNERSHIP =COUNfYAGENCY = FE ERALAGENCY <br /> ,CITY NAME STA ZIP CODE HONE a WITH AREA CODE <br /> Sa: Sl <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NE OO,FO NE`R' CARE OF ADDRESS INFORMATION <br /> MAILIN ORSTREET ADDRESS ✓ EmtuM Nes, Q INDIVIDUAL O LOCAL AGENCY Q STATE AGENCY <br /> D CORPORATION =PARTNERSHIP COUNTYAGENCY O FEIERALAGENCY <br /> CITY NAME STATJ I ZIP CODE PHONE a WITH AREA CODE <br /> 2 �O <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 /> ✓ Em b Indicate t SELF-INSURED 0 2 GUARANTEE 3 INSURANCE D A SURETY BOND <br /> 5 LETTER OF CREDIT O 6 EXEMPTION O Is OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sem 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: 1.0 II.0 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED a SIGNED) OWNER'S TRLE DATE MOfNTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY IF JURISDICTION a FACILITY• <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL 9UPVISOR-DISTRICT CODE -OPI]ONAI. �• <br /> O 3 •w <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS S A CHANGE OF SITE INFORMA OILY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) FOR01 i <br />