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yyyOU� [ <br /> STATE OF CALIFORNIA �� i� <br /> � o <br /> STATE WATER RESOURCES CONTROL BOARD W<� :; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILrTYISITE .` "a" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Q,5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY LO <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ B TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 81 ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMENAME OF OPERATOR <br /> ADDRESS NEARESTCROSS STREET+ J PARCEL a(OPTIONAL) <br /> CITY NAME STATE ZIP i SITE PHONE#WrrHW CJJDE <br /> CA <br /> TO INDICATE <br /> O CORPORATION INDIVIDUAL PARTNERS O LOCRICTS'CV CWMYAGENCY' O STATE-AGENCY' FFDERAIAGENCV' <br /> DSTRICTS' <br /> IT owner of UST Is a public agency,cor plete the following:name of Supervisor of diYBbn,section,or office which operates the UST <br /> TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR R SEF INDIIAN ON #OF TANKS AT SITE E.P.A. I.D.#(apNovg <br /> AT <br /> 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE/WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE 4 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box b MdbeN INDIVIDUAL LOCAL-AGENCY [1:1 STATE-MiENCY <br /> D CORPORATION PARTNERSHIP ED COUNTYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE I WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bcbiMbate = INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> Q CORPORATION O PARTNERSHIP COUNTY-AGENCY O FEOERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [4-T4--]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓6ovb M�caY 0 1 SELF-INSURED (]P GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> O 5 LETTER OF CREDIT D S EXEMPTION O SS OTHER <br /> Vt. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AI�fB'EORRECT <br /> OWNERS NAME(PRINTED 6 SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> Z % COUNTY# JUR`7 —`� FACILITY <br /> LOCATION CODE.}OPMNAL CENSUS TRACTh-OPTIC!MILr' 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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(3(93) <br /> FOR7017AM <br />