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x4W° <br /> STATE OF CALIFORNIA �� <br /> STATE WATER RESOURCES CONTROL BOARD + <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ug <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE �.<�°Qa+'- <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT 0 S CHANGE OF INFORMATION 7 PERMANEN ED SITE <br /> ONE REM 2 INTERIM PERMIT 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE 6/ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> gRAO. AGILITY NPIAENAME OF OPERATOR <br /> ADD ESS NEARES CROSS STREET PARCEL 0(OPiDNAL) <br /> CITY NAME - , STATE ZIP SITE PHONE It WITH AREA CODE <br /> BOX <br /> CA <br /> TO INDICATE 0 CORPORATION O INDIVIDUAL 0 PARTNERSHIP E-1 LOCAL-AGENCY ED COUITY-AGENCY' D STATE-AGENCY' D FEDERAL-AGENCY- <br /> N owner d UST Is a public S DSTPoCTS' <br /> p agency,mnplMe IM following:name of Supervisor of ENYXIn,section.I office which aparmes the UST <br /> TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN ISOF TANKS AT SITE E.P.A. I.D.#(upocruip <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR 0 5 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) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Fori <br /> MAILING OR STREET ADDRESS Q ✓En b INDIVIDUAL O LOCAL-AGENCY ED STATE.AGENCY <br /> CORPORATION [=1 PARTNERSHIP =CWNTYAGENCY [=1FEDEIMLACEI CY <br /> CITY NAME 9TATE ZIP ggDE PHONE f WITH AREA CODE <br /> AILL D <br /> 7 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS • ✓ pox b inEbals 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION E7:1 PARTNERSHIP (]COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALI�ZA71OON LIST <br /> 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 /> ✓Om bbdkils 1 SELF-INSURED Q 2 GUARANTEE 0 3 INSURANCE 4 SURETY BDND <br /> 0 71 <br /> 5 LETTEROFCREDR 8 EXEMPTION E�]w OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless <br /> box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.IlA IL D III. <br /> THIS FORM HAS BEENCOMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUES AND CORRECT <br /> OWNERS NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MCNTHIDAWVEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION• FACILITY t <br /> 0 3b <br /> LOCATIO -OPTIONAL CENSUS TRACT#,. BUPVISGR-DNLPUDE -OPTp <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATWNS <br /> FORM A(3 h FOROMMA7 <br /> Txc���TL-Z�� tv <br />