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'aa Ve � <br /> STATE OF CALIFORNIA „� i, <br /> STATE WATER RESOURCES CONTROL BOARD + <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE '-' <br /> MARK ONLY O t NEW PERMIT O 3 RENEWAL PERMIT5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT I AMENDED PERMIT �e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAO FACILITYNAME NAME OF CURATOR <br /> D S / <br /> ADD S ^ NEAREST CROSS STREET PMCELII(OPFIDNAL) <br /> ig <br /> CIN ME `\J , STATE Z CODE © � S s WITH AREA ODE <br /> C ,3 <br /> .1 BOX <br /> TOINp TE ISI CORPORATION I�INDIVIDUAL Q PARTNERSHIP I� LOCAL-AGENCY ED COUNTY AGENCY' 0 STATE-AGENCY' Q FEDEMLAGENCY' <br /> 'N oener d UST Is a db/Ec cy, rrp B DSTPoCTS' <br /> p agen a Isle the tolbwin :name W Su rv4or of dN4bn,s 011,or 01600 which operates the UST <br /> TYPE OF BUSINESS O t GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN IS OF TANKS AT SITE E.P.A. I.D.s(cpmendo <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR b OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY EMERGENCY CONTACT PERSON (SECONDARY)•opUonad <br /> DAYS: N ME(LAST,FIRS ANE WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> VTp <br /> NIGHTS: NAME(LASrf,FIRST) PHONE f WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONES WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Eos bind'ca11 O INDIVIDUAL LOCAL AGENCY STATEA(ELICY <br /> I=1 CORPORATION 0 PARTNERSHIP O COUNTYAGENCY FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa bkikate INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP Q COUNTYAGENCy FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE s 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 /> ✓ box to Indicate I SELF-INSURED O 2 GUARANTEE 3 INSURANCE O 4 SURETY BOND <br /> 5 LETTEROFCREOT 6 EXEMPTION D YD 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: I.O it.O 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 TIRE DATE MONTHIDAWYEAR <br /> LOCAL AGENCY USE ONLY r 1) g' <br /> COUNTY s JURISDICTION• FACILITY t <br /> LOCATION CODE -OPTAONAL CENSUS TRACT -OP,p,CINAL eUPVISOR-WSTRIOT CODE -CV110NAf. <br /> a. <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPUCATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> AM" OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS POmmDAaT <br />