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ttiWn t <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD + <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> C/ COMPLETE THIS FORM FOR EACH CILRYISITE <br /> MARK ONLY F7 1 NEW PERMIT 0 3 RENEWAL PERMIT ftlxCHANGE OF INFORMATION 0 7 PERMANENTLY O <br /> ONE REM D 2 INTERIM PERMIT Q l AMENDED PERMIT Q e TEMPORARY SITE CLOSURE <br /> I. FACILTTYISITE INF RMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAMEOFOPERATOR <br /> ADDRESS YI' NEMES CR0339TR6ETe / PNICEIa(OPfIGNAU <br /> i <br /> CITY NAME STATE ZIP i• SITE PHONEII WITH <br /> CA <br /> TOINDI RTE O CORPORATION O INDIVIDUAL O PMTNFAS ED pDCAL-A Ste' Y 0�MYAGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> If owner d UST h a public agency,completemd <br /> e the lollowlne;nae Superv4or of dNBsection,n,section,ISTRICor office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN Is OF TANKS AT SITE E.P.A. I.D.a ro➢No Wl <br /> RESERVATION <br /> 3 FARM Q N. PROCESSOR Q & OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST( PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS:NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓Oox bIMMM 11:1 INDIVIDUAL 0 LOCAL-AGENCY E::]STATE-A%NCY <br /> 0 CORPORATION O PARTNERSHIP C3 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME - --- —-- 8TATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓Eos badkYs INDIVIDUAL O LOCAL-AGENCY STATE AGENCY <br /> O CORPORATION PARTNERSHIP Q COUNrY-AGENCY ED FEDERAL-AGENCY <br /> CIT'NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ F4]-4-]-L_t_I I I I I . <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓hox bYdbaM Q I SELFINSURED O 2 GUARANTEE Q 3 INSURANCE Q N SURETY BOND <br /> D 5 LETTER OF CREDIT Q S EXEMPTION Q 90 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.El II. IIL <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY 10VOWLEDGE,IS TRUE AN RECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYMAR <br /> LOCAL AGENCY USE ONLY <br /> -- <br /> Z",-COUNTY N JURISDK:T • FACILITY S, <br /> LOCATION CODE -OP AL CENSUS 7iypT •Ole SUPVL90R-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUSt BE ACCOMPANIED BY AT LEAST(1)04 MORE PERMIT APPLICATION- FORM B,UNLESS THIS S A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) FOROUSANR <br />