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F ExEmPf- 7Q ►vKCNoto-n � w ► aT�►vkhr <br /> ♦ �/ V rb,bOVM <br /> r STATE OF CALIFORNIA �• o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A �e <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED $IT <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> orSC6 <br /> ADDRESS ' NEAREST CROSS ST ET PARCELN(OPTIONAL) <br /> CITY NAME _ STATE ZIP CODE SITE PHONE N WITH AREA CODE <br /> CA <br /> TOINDICCATE CORPORATIONINDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY O STATE-AGENCY [] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O I GAS STATION 0 2 DISTRIBUTOR0 RE� IF INDIAN SERVATION x OF TANKS AT SITE E.P.A. I.D.!(Wicnal) <br /> © 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY ' NAME( ST FIRSTA PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> Q:icoC . otp <br /> NIGHTS: NAME(LAST,FIRST) PHONE OANITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> ll. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILINBTREET ADORES <br /> / ✓ boxbintlinie 0 INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNrY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE•WIT AREA CODE <br /> to <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) ��VAOy <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box blMbm, 0 INDIVIDUAL D LOCAL-AGENCY O STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY 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) Hp 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bax blMkala 0 I SELF-INSURED O 2 qWANTEE M 3 INSURANCE 0 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT EXEMPTION O 99 OTHER <br /> 771 <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: 1.0 IL III.❑ <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) APPLICANT'S TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JURISDICTION R FACILITY <br /> m F-FT-1 4 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT! -3 OPTIONALa--- <br /> SUPVISOR-DISTRICT CODE - NAL <br /> I a <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) `- ����� I� �� f � r q FOROIXi3A`/J <br />