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noun e <br /> •xI STATE OF CALIFORNIA .` o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> / UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A >a <br /> G/ COMPLETE THIS FORM FOR EAC ACILRYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PE LY C ED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> FADORESS <br /> ME �C \� 1� v NAME OF OPERATOR <br /> 0 / NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> � � STATE ZIP CODE / SITE PHONE#WITH ARE✓CODE <br /> CA V CCGG o <br /> I/ BOX <br /> O CORPORATION O INDIVIDUAL O PARAERSHIP LOCALCTSENCY 0 COUNTY-AGENCY f�STATE-AGENCY ED FEDERAL AGENCY <br /> DISTRITYPE OF BUSINESS O i GAS STATION 0 2 DISTRIBUTORpESEF INDIAN <br /> N x OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 4 PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE A WITH <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(L 1,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bbdbate I:1 INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> O CORPORATION = PARTNERSHIP COUNTYAGENCY = FEDERAL-AGENCY <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 ORSTREETADDRESS ✓ box 0bdk9N (] INDIVIDUAL LOCAL-AGENCY E-J STATE-AGENCY <br /> CORPORATION 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(9 16)323-9555 if quesfions arise. <br /> TY(TK) HQ F4—T4]- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box biMbate I SELF-INSURED 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> O 5 LETTEROFCREgT Q 6 EXEMPTION 99 OTHER <br /> 71 <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O IL= III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PR INTED B S IGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR/ <br /> Z W✓ <br /> LOCAL AGENCY USE ONLY <br /> CO ��� JURISDICTION �� '1 FACILITY / <br /> GPM CODE -GPCENSUS TRACT# -OPTIOAUL SUPVISOR-DISTRICT CODE -OP NAL <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS TjilS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A15-91) FORMA <br /> n <br /> `✓ ���� <br />