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Yes u° ` <br /> STATEOFCAUFORMA ^. °°: <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A "mL� ue <br /> Y C�x��°YY�� <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION FV7 PERMANENTLY CLOSED SITE <br /> ONE REM O 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 0 e TEMPORARY SITE CLOSURE x5Z <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA R <br /> ACI NAME NAME OF OPERATOR <br /> ro <br /> ADD E NEAREST CROSS STREET PARCEL 9(OFRIONAp <br /> qj0 <br /> yy <br /> CITU NAM STATE ZIP CODE— SITE PHONE•WITH AREA CODE <br /> 67 CA <br /> TOINq RATE (]CORPORATION INDIVIDUAL 0 PARTNERSHIP Q LOCAL-AGENCY COUNrY-AGENCY O STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR 1 RE/ IF INDIAN SERVATION A OF TANK$AT SITE E.P.A. I.D.%(gNNna// <br /> O 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓Wx birdkam 0INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION O PARTNERSHIP COUNTY AGENCY 0 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 OR STREET ADDRESS v box r&mah, INDIVIDUAL LOCAL-AGENCY STATE AGENCY <br /> =CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 44 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMP ED)—IDENTIFY THE METHOD(S) USED <br /> ✓box b Intlkala E=1 t SELF INSURED [__1 AUARANTEE Q 3 INSURANCE O 4 SURETY BOND <br /> E-1 5 LETTER OF GREW a EXEMPTION O 99 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: 1.0 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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 37 F-1-17 <br /> LOCATION COD - TIONAL CENSUS TRACT a - ALA yj� SUPV5-OIST ICT 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 /> FORM A(5-91) F R0033A-5 <br />