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sso�^ e <br /> STATE OF CALIFORNIA c <br /> a, <br /> STATE WATER RESOURCES CONTROL BOARD '��� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A ve <br /> COMPLETE THIS FORM FOR EACH FACILrrYISTTE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SrTE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> D FACILITY E NAME <br /> V -/�u7111�A <br /> NEAREST CROSS PARC REET PMCEL#IOPFIONALj <br /> CITY NAME # STATE ZTE PHONE#WITH AREA CODE <br /> � CAV Box <br /> TOINDICATE O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP O LOCA4AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> dl DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR0 ✓ IF INDIAN #OF TAN S AT SITE E.P.A. L D.#(optional) <br /> RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR V, <br /> OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PwnN <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> HE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME 01 CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS s ✓ tOXII)I ab 0INDIVIDUAL LOCALAGENCY STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY Q FIEDERALAMNCY <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 ✓boa toiMicak D INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> (]CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY 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) HO L4 4 -0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP ETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Eos biMbate C I SELF INSURED 0 JAUARANTEE = 3 INSURANCE <SURETY BOND <br /> I. 5 LETTER OF CREDIT ELf6 EXEMPTION 0 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: L❑ II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTSTITLE DATE MONTHDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTI AL ICENSUS TRA # OPTI gq SUPVISOR-OISTRI TCOOE - P A�1� <br /> A 10- <br /> THIS <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS HIS IS A CHANGE OF FORMATIKit <br /> FORM A(12rep FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULA WS Q,�pe��• � <br />