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STATE OF CALIFORNIA <br /> i STATE WATER RESOURCES CONTROL BOARD i <br /> j LINDERGROU ANK PERMIT APPLICATION - FORM A •�� '` <br /> COMPLETE THIS FORM F CHFACILRYISITE .� `•�rroe+" o <br /> MARK ONLY RMIT 3 RENEWAL PERMIT CH GE OF INFORMATION 0 7 PERMANENTLY CL <br /> ONE IT Q 2 INTERIM PERMIT a AMENDED PERMIT a s TEMPONARY SITE CLOSURE <br /> I. F ILITYISITE INFORMATION& ADDRESS- MUST BE COMPLETED) <br /> DB OR FACILITY NAME 0 1AMEOFOPERATOR <br /> RESS NEMESTCROSS ETRE PMICELIIOPrgNAU <br /> CI E STATE ZIP SITE PHONE s WITH AREA CODE <br /> 12-d CA <br /> TO IN X f�CORPORATION (] MVDUAL PARTNERSHIP LO-AGENCY l�CWNTY-AGENCY' l�SGTE-AGENCY• f� iFDERAL-AGENCY' <br /> •5 owner of UST le a agency.complete the fo9owMg:name of Supervisor of oNisbn,seal .m which operates the UST <br /> TYPE OF BUSINESS O I GAS ✓ IF INDIAN IS OF TANKS AT SITE E.P.A. I.D.Is fopmo ag <br /> 3 FARM Q a PROCESSOR Q 5 OTHER OR TRUST ATION <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTA P SON (SECONDARY)-5ptlonal <br /> YS: KAME(LAST,FIRST) P}IONE Is WITH AR / DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST 3T) PHONE a WITH AREA CODE NIGHTS: NAME(LASST..`FIRSRS' AREA CODE <br /> 11. P NFORMATION- MUST BE COMPL <br /> NAM ARE OF ADDREINF NATION <br /> D I <br /> AILING OR STR_5&TADDRESS ✓Dox Is noose = INDIVIDUAL (] LOCAL-AGENCY STATE AGENCY <br /> D (//✓ ?�/ O CORPoRA70N PARTNERSHIP W <br /> 49'LCNTYA ENCY FEDERAL AGENCY <br /> 1TY•NAME STA ZIP CODE L/ PHONE i NTH AR <br /> 1. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> S: <br /> .n CARE OF ADDRESS INFORMATION <br /> MAILING OR S=S W s-V`c ✓ p%p� y Q INDIVIDUAL LOCAL AGENCY AGENCY <br /> CD CORPORATION D PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE 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- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Ow aYWee O I SELF-INSURED 2 GUARANTEE O 3 INSURANCE a SURETYBOND <br /> 5 LETTER OF CREW O 5 E7EMPnoN 99 OTHER <br /> 3 <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unl s box I or II is d. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. If.y III <br /> T141S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRU D CORR <br /> OWNERS NAME(PRINTED B SIGNED) OWNER'S TRUE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY W <br /> \�` V <br /> COUNJY# JURISDICTION# FACILITY# <br /> L 101CA CpDE -CPipNAL CENSUS TRAC a -OP SSUPVIT DISTRICT CODE •OP7101/AL <br /> THIS FOAM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS tS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS — y <br /> 7 <br /> FORMA(393) <br /> FCR 3 A <br />