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0Va <br /> STATE Of CALIFORNIA `t <br /> STATE WATER RESOURCES CONTROL BOARD sy <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> �� COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY NEW PERMIT n 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CL09OD, <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR A NAME /7 NAMED ERATOR <br /> K1174 <br /> T ?UVAW <br /> ADD 1 NEAREST VSS STREET PARCEL#(OPfIONAL) <br /> CITU N STATE ZIP DE o SITE PHON-# AidEAgF <br /> CA 51 <br /> TO INDICATE O CORPORATION E:J INDIVIDUAL E::] PARTNERSHIP E::] LOCAL-AGENCY O COURTY-AGENCY STATE-AGENCY E-1 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR REE' IF INDIAN <br /> 10N #OF TANKS AT SITE E.P.A. I.D.#(0ohmal) <br /> O 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST.FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> Il, PROPERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> AA <br /> MAILING OR STREET ADDRESS ✓ bD[MMica Q INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION PARTNERSHIP O COUNTY-AGENCY O FEDERALAGENCY <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 STREET ADDRESS ✓ boarNkete D INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> l�CORPORATION l= PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ [4x-14 7 1J L'1J <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ Eos mirAicam C7 1 SELF INSURED lV UARANTEE D ] INSURANCE l�4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION %OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unles)Lox I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.O 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) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY f5A C <br /> COUNTY# JURISDICTION# FACILITY# <br /> ,39 TLS , <br /> LOCATI!n OPTIONAL 3 U <br /> (CENSUS TRACT: - TfQNAL SUPVISOR-DDISTRICT OD -OPjJQN][, <br /> ✓GG <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLE S THIS IS A CHANGE OF SITE INFORMATION LY. <br /> FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TA�LATIONS <br /> FOR0093A-R6 <br /> T <br />