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1 Juw <br /> STATE OF CALIFORNIA oti <br /> STATE WATER RESOURCES CONTROL BOARD .'y <br /> wtB <br /> �. UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 3�� ye <br /> COMPLETE THIS FORM FOR EACH FACILITY/SfTE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMIAN LOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE Q <br /> I. FACILITY/SITE INFORMATION 8 ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> d- aS <br /> ADDRESS NEAREST CROSS STREET PARCEL#rOPTIONAU <br /> T 2 <br /> CITY NAME -7 �2 ST - ZIP CODE / SITE PHONE.WITH AREA CODE <br /> 6 6 -0 -1'1 <br /> v Box TOINDICATE O CORPORATION Q INDIVIDUAL Q PARTNERSHIP O D LOCA <br /> rn-AG <br /> SENCY 0 COUNTY-AGENCV STATE AGENCY O FEDERAL-AGENCY <br /> TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR ,/ IF INDIAN .OF TANKS AT SITE E.P.A. I.D. (Dpfrmal) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE.WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE <br /> A WITH AREA <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bOdbau 0 INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION = PARTNERSHIP O COUNTY-AGENCY Q FEOERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE.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 iMkw 0INDIVIDUAL Q LOCAL AGENCY D STATE AGENCY <br /> CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4-T-41-L V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ WX 0imk O I SELF-INSURED GUARANTEE Q 31NSURANCE Q d SURETVBOND <br /> =5 LETTEROFCREDIT a 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: I.❑ II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRWTED A SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY» �� JURISDICTION# T/ �� 0ACILfrYu I- J�I�, <br /> up� TLTLra/ I C7 �r,Jw <br /> LOCATION CODE -OPT/ L (CENSUS TRACT.-OPT; ISUPVISOR-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 /> FORMA(5-e1) <br /> FOR0033A-5 \ <br />