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�+ sou. <br /> STATE OF CALIFORNIAo <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :� . <br /> COMPLETE THIS FORM FOR EACH FACILIrYISITE °•��.o.•'' o <br /> MARK ONLY D 1 NEW PERMIT 0 3 RENEWAL PERMIT Q S CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SiTE <br /> ONE REM O 2 INTERIM PERMIT Q d AMENDED PERMIT Q e TEMPORARY SITE CLOSURE 102-1 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> I OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS TREET PARCEL#(OFrIONAU <br /> 1 <br /> CITY NAME STATE Z CODE SITE PHONE WITH AREA CODE <br /> CA <br /> TOINDIICCATE O CORPORATION O INDIVIDUAL 0 PARTNERSHIP O �ALLCTGENCY COUNTYAGENCY• O STATE-AGFRCV' 2rf&RALAGENcY <br /> X owner of UST Is a pubbc agency,mnWele the fobowing:name of Supervba of division.section,or office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR q-/ IF INDIIAN ON a OF TANKS AT SITE E.P.A. I.0.a(opfbMQ <br /> 0 3 FARM Q A PROCESSOR 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE f WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> i_5 t79 4(1-5— <br /> N IGHTS: <br /> SNIGHTS: NAM (�l4T.FIR a WITHAREACOOE NIGHTS: NAME(LAST,FIRST) PHONE f WITH AREA CODE <br /> � PHONE p <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> LINGORSTREETADDRESS ✓box bbec#e ED INDIVIDUAL 0 LOCAL-AGENCY E STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP 0 COUNTYAGENCY 0 FEDERAL4AENCY <br /> CITY NAME SITE ZIP DE PHONE a WITH AREA CODE <br /> k. � <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING ORS REET ADDRESS ✓ bmbiMYau O INDIVIDUAL O LOCAL AGENCY D STATE AGENCY <br /> ED CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY D FEDERALAGENCY <br /> CITY NAME 9TATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ IKE- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Wr b iMkale D 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE O A SURETY BOND <br /> O s LETTEROFCREDIT O 6 EXEMPTION D TO OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless bo 1 or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: Le 11.0 III.0 <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'STITLE DATE MONTWDAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JU?RISD�K:TKNJ# FACILITY# <br /> EE]BE l: <br /> LOCATION CODE-OPTIONAL CENSUS TRACTo -OPTIONAL SUPVISOR-DISTRIT CODE -OPTIONAL <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) FOR6071AA7 <br />