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w" e <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A W �; <br /> COMPLETE THIS FORM FOR EAC CILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSgQ.LrrE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT E 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) < r <br /> DRA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEARE T 9ROSS STREET PARCEL#(OPTIONAL) <br /> d Gird z <br /> CITY NAME STATE ZIP �QE_ SITE PHONE#WITH AREA CODE <br /> I/ BOX <br /> BO% 3 K <br /> TOINDICATE O CORPORATIONINDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY Q STATE-AGENCY Q FEDEMLAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D. <br /> RESERVATION <br /> 0 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS' NtME(LAST,FIRS PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGH). NA E(LAST, IRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> _ _ L <br /> MAILING OR STREET ADDRESS ✓box bir&&N, INDIVIDUAL AL.AGFNCY STATE-AGENCY <br /> 5 =CORPORATION Q PARTNERSHIP Q COUNTYAMNCY FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE 3 PHONE#WITH AREA CgOE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETE ) S <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box biMkara INDIVIDUAL 0 LOCAL-AGENCY (] STATE AGENCY <br /> 0 CORPORATION O PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CIT-NAME STATE ZIP CODE PHONE x WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(9 16)323-9555 if questions arise. <br /> TY(TK) HQ F4 4 1.-F1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bm biMicale _i I SELF INSURED 2 GUARANTEE 0 3 INSURANCE 0 4 SURFTY BOND <br /> — 5 LETTER OF CREDIT 6 EXEMPTION (] W 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: 1.O EX III.El <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/OAVNEAR <br /> d -a <br /> LOCAL AGENCY USE ONLY <br /> COUNTY JURISDICTION# FA ITY# <br /> LOCATION CODE OPTIONAL iCENSUS TRACT#OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 /> FORM A(12 ell FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0033A-R6 <br /> i <br />