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STATE OF CAUFORMA, <br /> STATE WATER RESOURCES CONTROL BOARD {� •� P 5 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A <br /> n <br /> II^^ COMPLETE THIS FORM FOR EAC ACILITYISITE <br /> MARK ONLY U I NEW PERMIT r 3 RENEWAL PERMIT 5 CHANCE OF INFORMATION RN CLO SITE <br /> GNE ITEM �j 2 INTERIM PERMIT (�� a AMENDED PERMIT 8 TEMPORARY SIZE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME /�� I NAME OF OPERATOR <br /> ADDRESS c NEAREST CROSISTREETPARCEL I,(OPTIONAL) <br /> � S TVA 4CITY NA-AE STATE21P SITE PHONE#WITH AREA CODE <br /> / ca 37 L Z� - sBox a <br /> TO CICATE N 0,04M. =I PARTNERSWP 17 LOCAL-AGENCY Q CWNTYAGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DBiTRICTS <br /> TYPE OF BUSINESScvI GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #CF TANKS AT SITE E.P.A. L O.#IOPI) <br /> RESERVATION <br /> 3 FARM A PROCESSOR Q 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(AST.FIRST) <br /> M 43S---7"10Q <br /> NIGHTS:NAME(LAST.FIRv, PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> F♦WITH, qc nuc <br /> It. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME I CARE OF ADDRESS INFORMATION <br /> MAILING CR STREET ADDRESS ✓ I c#IacaM 0 INDIVIDUAL MI LOCAL-AGENCY CI STATE-AGENCY <br /> Q CORPORATION p PARTNERSHP Q CWNtY#GENCY FEDEM.W.ENCY <br /> CITY NAME STATE I ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAKING OR STREET ADORES$ ✓ ewo#MKM# C:D INDIVIDUAL Q LOCAL-AGENCY a STATE-AGENCY <br /> CORPORATION Q PARTNERSHP Q COUNTY.AGENCY a FEDERAL#GENCY <br /> CITY NAME I 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 F474 I- d 6 0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOO(S) USED <br /> V Om biNiM4 0 I SELFINSUAED =2 GUARANTEE (] 3 INSURANCE <br /> A SURETY FOND <br /> 0 S LETTER OF CREOT O B EXEMPTION O 9➢OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent lathe tank owner unless x I or ll•s checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1,pt IL 114 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLCANTS NAME IPA INTEO A SIGNATURE) APPLICANT'S TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY#1/ u v <br /> ® mT b <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OP SUPVISOR•DISTRICT CODE •OPTIONAL <br /> 63 23 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) <br /> FORBLLTSA.S I / <br />