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� '460JM <br /> STATE OF CALIFORNIA o°?, <br /> 'r STATE WATER RESOURCES CONTROL BOARD 4 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> Xxnn ...: o <br /> �IpPN` <br /> i� COMPLETE THIS FORM FOR EACH FACLRYISITE <br /> MARK ONLY l—I 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 1 <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> D <br /> ADDRESS NEAREST CROSS STREET PARCEL*(OPnONAL) <br /> Shu o ee— <br /> CITYNAME STATE ZIP CODE SITE PHONE WITHAREA CODE <br /> v BOX <br /> TO INDICATE O CORPORATIONIBJ INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY Q COUNTY AGENCY 0 STATE-AGENCY l� FEDERAL AGENCY <br /> '` DISTRICTS <br /> TYPE OF BUSINESS I GAS STATION 0 2 DISTRIBUTOR I <br /> 0 RV IF INDIIAN ON M OF TANKS AT SITE E.P.A. 1.0.#WfibnaQ <br /> O AT <br /> 3 FARM 4 PROCESSOR X 5 OTHER Ofl TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY AME(LAST,FIRST) PHO* %WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> ao - PHONE S WITH AREA CODE <br /> - <br /> NIGHTS: NAME( .FIRST) PHONE WITH A EA CODE NIGHTS: NAME(LAST,FIRST) <br /> 1 1 1 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING STR ET ADDREGS ✓ boxblMkNe Q INDIVIDUAL LOCAL-AGENCY E-D STATE-AGENCY <br /> E:::]CORPORATION Q PARTNERSHIP O COUNTY-AGENCY E=1 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE•WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADORESS ✓ box blMkab E�:] INDIVIDUAL LOCAL-AGENCY STATE AGENCY <br /> l�CORPORATION L-1 PARTNERSHIP D COUNTYAGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ [4T4-]-16 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Fox bimicara Ll I SELFINSURED 2 GUARANTEE [-1 31NSURANCE 0 4 SURETY BOND <br /> I _I 5 LETIEROFCREDIT 6 EXEMPTION W OTHER <br /> 71 <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: 1.ly IL[—] 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&SIGNATURE) APPLICANT'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY s j C^ <br /> COUNTY N JURISDICTION If FACI <br /> LOCATION CODE -OPTIONAL .CENSUS TRACT* 'OP SUPVISOR-D0DO OPTIONAL <br /> ISTRICT <br /> THIS FORM MUST AE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> POEM A 02 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOROOJJ <br />