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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> 1 NEW PERMIT <br /> MARK ONLY 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATN)N 7 PERMANENTLY CLO <br /> ONE REM O 2 INTERIM PERMIT Q d AMENDED PERMIT O S TEMPORARY SITE CLOSURE L� <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> ARA O. FIll .ME <br /> NAME OF OPERATOR <br /> ADDRESS ^ NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> Cl <br /> STATE ZIP CODE SITE PHONE Ar WITH AREA CODE <br /> — G4CA <br /> TOINDICATE O CORPORATION D INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> N owner of UST is a public DISTRICTS' <br /> p agency,aoglele iM following:name d Supervisor d tlNYbn,rscibn,or office which operates the UST <br /> TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.i to; <br /> lrpW) <br /> ON <br /> 3 FARM 6 PROCESSOR OTHER OORTESEgUST LANDS / <br /> I VTI <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAVNA ST,FIRST) PHONE a WITH AREA CODEI qAYS: NAME(LAST,FIRST) PHONE WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE ff HA EA CODE NIGHTS: NAME(LAST,FIRST) PHONEl WITH AREA CODE <br /> (1 11 <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Ooxbintlkale 0 INDIVB]UAL I� LOCAL-AGENCY Q STATE-AGENCY <br /> (]CORPORATION = PARTNERSHIP O COUNTY-AGENCY D FEDERAL WENCY <br /> CITY NAME STATE ZIP CODE PHONE 0 WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STRUTADDRESS ✓box b NdlCNa 0 INDIVIDUAL O LOCAL-AGENCY E=1 STATE-AGENCY <br /> CORPORATION D PARTNERSHIP Q COUNTY AGENCY =FEDERAL#GENCY <br /> CITY NAME STATE ZIP CODE PHONE l WITH AREA CODE <br /> IV. BOARD OF EpUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO M44- - (� a <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box biMicale I�I SELF INSURED 2 GUARANTEE 3 INSURANCE (]A SURETY BOND <br /> 5 LETTER OF CREOIT O 6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is chocked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.D III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY o2� <br /> COUNTY! JURISDICTION It FACILITY! A"O(Ou <br /> a17I A� ) <br /> LOCATION C� -OPTTOAW. CENSUS TRACT#-O-OPTIONAL `� SUPVISOR-DISTji � - <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM V'rrH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROW'^STORAGE TANK REGULATIONS <br /> FORM A CM FORMUA7 <br /> 0•..')Liq <br />