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STATE OF CAUFORMA ��� <br /> STATE WATER RESOURCES CONTROL BOARD s' <br /> 8 f UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A W,�� "` <br /> COMPLETE THIS FORM FOR <br /> EACH FACILRYISITE °.�„n��,��D <br /> MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT 17�5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED S1TE <br /> ONE REM O 2 INTERIM PERMIT a AMENDED PERMIT rO 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAO FACILITY NAME NAME OF OPERATOR <br /> Zqb <br /> ADDRE89 ^ NEAREST CR033 STREET PARCEL 0(OPfIONAL) <br /> CITU NAME U - STATE ZIP SITE PHONE i WITH AREA CODE <br /> CA <br /> Box TO INDICATE O CORPORATION JNDIADUAL 0 PARTNERSHIP I� LOCAL-AGENCY 0 COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL.AGENCY' <br /> 'N baser d UST is a public a DISTRICTS <br /> p agency,corrWete the following:name d Supervbor d tlNkbn,sedbn,or oXim which operates the UST <br /> TYPE OF BUSINESS C5el GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN !OF TANKS AT SITE E.P.A <br /> 6 OTHER I.D.!(ppbWl <br /> 0 3 FARM Q 4 PROCESSOR E RESERVATION <br /> O OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME( T,FIRST) PHONE 0 WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE!WITH AREA CODE <br /> a+ bw <br /> NIGHTS: NAME(LAST,FIRST) PHONE l WITHAREA GUIDE NIGHTS:NAME(LAST,FIRST) PHONE S WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME I I CARE OFA FIESf INFORMATI <br /> MAILING OR STRET ADD E S ✓ I <br /> W. L-j INDIVIDUAL O LOCAL-AGENCY O STATE AGENCY <br /> CI S a I�CORPORATION PARTNERSHIP =COUNTYAGENCY FEDERALAGENCY <br /> STATE ZIP CODE PHONE l WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box bintlbee L-j INDIVIDUAL (] LOCAL-AGENCY O STATE-AGENCY <br /> CRY NAME O CORPORATION 1D PARTNERSHIP O COUNTY-AGENCY O FEDERALAGENCY <br /> STATE ZIP GUIDE PHONE 0 WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ F4-F4--]- a ;2 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ hocbbSoaM O 1 SELF-INSURED 0 2 GUARANTEE L-j 3 INSURANCE <br /> O 5 LETTEROFCREDT E::]6 EXEMPTION 0 A SURETY BOND <br /> Q 9B OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II. III.El <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY e D <br /> COUNTY x JURISDICTION i FACILITY r <br /> LOCAno CODE -CpTX1NAL CENSUS TRACT!-OPTpNAL 9UPVIS00.-DISTRICT CODE -OP <br /> D 31 660 <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 /> FORMA(SAGS) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> /fes FOR0053M 7 <br />