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goun <br /> STATE Of CALIFORNIA ...... `o <br /> r <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> / UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ve <br /> v <br /> Cnx��fln M� <br /> COMPLETE THIS FORM FOR EACH LITYISITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION ❑ 7 PER NEN O D ITE <br /> ONE ITEM (❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DRAOR FACILITY NAME N EOFOPERATOR <br /> ADDRESS N REST CROSS STREET PARCEL#(OPTIONAU <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> CA S <br /> ✓ Box <br /> TO INDICATE D COflPORATION INDIVIDUAL 0 PARTNERSH LOCAL-pGENCV COUNTY-AGENCY O STATE-AGENCY 0 FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR I = ✓ IF INDIAN x OF TANKS AT SITE E.P.A. I.D.A(optimal) <br /> HE <br /> 0 3 FARM O 4 PROCESSOR E14 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAMEAS IYRST) N N NE a WITH A_UA CODE DAYS'. N ( AST,FIRST) <br /> i <br /> NIGHTS: NAME(LAST,FrrPHONE#WITH AREA DE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILINGOR STREET ADDRESS ✓ bow bintlkLA 0 INDIVIDUAL LOCAUAGFNCY <br /> E::] STATE-AGENCY <br /> _ E-1 CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY ED FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a 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 bindicate E=) INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION O PARTNERSHIP [_1 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) HO [4 [4]-n ]== <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Dox <br /> W.M. L_] I SELF-INSURED CI 2 GUARANTEE 0 3 INSURANCE O a SUflETYBOND <br /> 0 5 LETTER OF CREDIT 0 6 EXEMPTION BB 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: LE] 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) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> 9 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 39 TT <br /> LOCATION COD OPTIONAL ICENS T T -OPSIONAL I SUPVISOR DISTRICT CODE -OPTIONAL <br /> THIS FbFrA MUST BE ACCOMPANIED BY AT LEAST(1))OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FDRM A OP en FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0033A-R6 <br />