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tI V� C <br /> 4 <br /> " C M1i <br /> STATE OF CALIFDRWA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �. . <br /> COMPLETE THIS FORM FOR EA FACILTTYISITE <br /> T NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY <br /> ONE REM Q 2 INTERIM PERMIT 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION S ADDRESS-(MUST BE COMPLETED) <br /> D FACILIIN E //' AMEOFOPERAT R f'I <br /> G r►se ry <br /> ADDR SS� <br /> A EST SS SIRE PARCELI(OPTMAL) <br /> CITY STATE ZIP „7 q 3 E a W A CODE <br /> CA [/nGU <br /> TO RBox CATE O CDR RATION D INDIVIDUAL PARTNERSHIP LOCAL-AGENCY Q CWNTYAGENCY' O STATE-AGENCY' FEDERAL-AGENCY' <br /> DSTRICTS' <br /> II owner of UST Is a public .ceplplete the following:narre of Supervisor of d"Ion,section,or office which operet"the UST <br /> TYPE OF BUSINESS i GAS STATION Q 2 DISTRIBUTOR q EIF RVATDION I OF TANAT SITE E.P.A. I.D.#(optional) <br /> S <br /> 0 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optimal <br /> DAYS:NAME(LAST,FIRST) PHONE I WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMEHin -wp <br /> I CARE OF ADDRESS INFORMATION <br /> I <br /> MAILOR T TADDR S ✓ babbdbale O INDIVIDUAL LOCAL-AGENCY STATEAGENCY <br /> RL Q� 0 CORPORATION PARTNERSHIP COUNTYAGENCY FEDERALAGENCY <br /> CITYNAME, ST ZIP�°�52� PHONE#WITH AREACODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET—ADDRESS ✓box rdbMl Q INDIVIDUAL D LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION Q PARTNERSHIP COUNrYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#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 4- -10 1 S]4 111514 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECOMP ETED)—IDENTIFY THEMETHOD(S) USED <br /> ✓ fix b =i SELF-INSURED 0DftARANTEE O 3 INSURANCE O 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT lure EXEMPTION = N OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless A I or II is Checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.Y II.O It. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED It SIGNED) OWNERS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTYI JURISDICTION# �� FACLLrTV# <br /> LOCAT N DE -OPTIONAL CENSUSjRArT#-pP;pNAI SUPVISOR- � I <br /> z- EVA <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 FILETHIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3A3) �p FORaa73AA7 <br /> F1 h cc 398 9 12/10 -2 3//31 aW ��Is�y 3 <br />