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60JR <br /> STATE OF CALIFORNIA o0 <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> i UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�� "�; <br /> COMPLETE THIS FORM FOR EACH FACILrTY/SITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT [_] 5 CHANGE OF INFORMATION V 7 PERMANENTLY CLOSED SITE�] <br /> ONE REM 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA F ILITY NAM NAMEOFOPERATOR <br /> JCIA <br /> SS NEAREST CROSS STREET PARCEL#(OPTIONAL) _ <br /> aEV <br /> STATE I SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓ <br /> TO INDICATE 17=1 CORPORATION D INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY 0 COUNTYAGENCV <br /> DISTRICTS D STATE-AGENCY D FEDERALdGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION I� 2 DISTRIBUTOR ✓ IF AN <br /> #OF TA KS SITE E.P.A. I.D.#teptiona# <br /> 3 FARM E::] 4 PROCESSOR 5 OTHER O RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA DODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRSn PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ IDI"WED INDIVIDUAL Q LOCAL AGENCY O STATE- <br /> AGENCY <br /> O CORPORATION = PARTNERSHIP [] COUNTY-AGENOy 0 FEDERAL-AGENCY <br /> CIT-NAME STATE ZIP CODE PHONE WITH AREA CODE <br /> III. TANKOWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADORESS- ✓box bh*ale INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION LIST SSTO�RAAGGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4KI-VJ�:1L7-I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-MUST BE COMPL D)—IDENTIFY THE METHOD(S) USED <br /> ✓ Luo to kaze 0 1 SELF-INSURED Q 14ARANTEE 3 INSURANCE A SURETY BONG <br /> D 5 LETTEROFCREDIT LV6 EXEMPTION E7 6B 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: I.[__j II,F-] III.O <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 8 SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# I14��J <br /> LOOATIO -OPTIONAL CENSUS TI]ACTI -OPP ONAL SU�OC DIS�TCOOE -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.f <br /> FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGUy♦yTIONS <br /> /b FORO6113AR <br />