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♦eNn <br /> STATE OF CALIFORNIA ee' c Ti <br /> STATE WATER RESOURCES CONTROL BOARD W., a a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �, <br /> COMPLETE THIS FORM FOR EACH FACILrTY/SITE �.o.w" <br /> MARK ONLY C 1 NEW PERMITrnr � 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SiT <br /> EM E <br /> ONE T —i 2 INTERIM PERMIT u 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA , COLI :AME / ' � NAME OF OPERATOR <br /> ( J <br /> ADDR D �_� NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> I <br /> CITY NAME STATE ziPcaDE SITE PHONE a WITH AREA CODE <br /> / CA O Ca <br /> TO INCNTECORPORATION INDIVIDUAL 0 PARTNERSHIP LOCA4AGENCY CWNIY-AGENCY' O STATE-AGENCY' 0 FEDERALAGENCY' <br /> M/1 DISTRICTS' <br /> N owner d UN ST a Ic agency,mnplde the folowing:name or Supervisor of dNlabn,uclbn,w offim which operatee the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR0 RE/ IF INDIIAIAN N a OF TAN AT SITE E.P.A. 1.D.a(opliaW) <br /> 0 3 FARM Q 4 PROCESSOR 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(UST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box bhecab [D INDIVIDUAL 0 LOCAL-AGENCY ED STATE-AaENCV <br /> CD CORPORATION O PARTNERSHIP 0 COUNTYAGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION- (MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ba bhnxic INDIVIDUAL (] LOCAL-AGENCY Q STATE-AGENCY <br /> O CORPORATION 0 PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE 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 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bot 0i .Ie I SELF-INSURED Ij 2 GUARANTEE 3INSURANCE O 4 SURETY BOND <br /> f� 5 LETTER OF CREDIT 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 II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II.Q III El <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 MOfNTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY f <br /> &I 0AA1 I DA <br /> LOCATIO -OPTIONAL CENSUS TRACT# -0 SUPVISOR-DISTRICT 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 /> (393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UND GROUND STORAGE TANK REGULATT <br /> ffiFORMA l ,L 3 (?-7 P ire FGROM3A-R7 <br />