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STATE OF CALIFORNIA -- •`' \ <br /> STATE WATER RESOURCES CONTROL BOARD '' c <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A <br /> COMPLETE THIS FORM FOR EAJ&FACILIrYISiTE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT J <br /> ONE REM 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED <br /> ❑ 2 INTERIM PERMIT ❑ 1 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA p%nCILITV E <br /> ,/ N ME OF OPERATOR <br /> ADORES <br /> NE STCROSS TR Er PARCEL#(OPTIONAL) <br /> CITY NAME <br /> STATE ZIPC � SITE PHONE+WITH AR � <br /> ✓ CA Ln <br /> TO INDICATE O CORPORATION INDIVIDUAL (]PARTNERSHIP Q LOCAL-AGENCY <br /> h owner of UST is a ublic DISTRICTS' 0 COUNTY-AGENCY' STATE-AGENCY• O FEDERAL p apenq,oonplpe the following:name Of Supervisor of d"ion,mglon,W 010)which operate the UST <br /> TYPE OF BUSINESS ❑ , GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN A OF TAN T SITE E.P.A. I.p,+((gNny(I <br /> ❑ 3 FARM O / PROCESSOR ❑ 5 OTHER �OR TRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> PAYS: NAME(LAST,FIRST) EMERGENCY CONTACT PERSON (SECONDARY).oPllonal <br /> PHO WITH AREA CODE <br /> DAYS: NAME()AST,FIRST) PHONE+WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE NIGH I.: NAME(LAST,FIRST) <br /> PHONE WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME <br /> CARE OF AppgESS INFORMATION <br /> MAILING Oq STREET ADDRESS ✓ om biMhaq <br /> INDIVIDUAL = LOCA)-AGENCY STATE-AGENCY <br /> CITY NAME (]CORPORATION 0 PARTNERSHIP IJ COUNTY AGENCY 0 FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE+WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ApDRESS ✓ Om bwlaicau <br /> O INDIVIDUAL O LOCA4AGENCY 0 STATEAGENCY <br /> CIN NAME O <br /> CORPORATION PARTNERSHIP Q GOUNfYAGENCY O FEDERAL AGENCY <br /> STATE "'CODE PHONE+WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION <br /> /UST <br /> TSTORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HD 4 4- - L <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boobindk l Q I SELF.INSURED Q P GUARANTEE 3 INSURANCE <br /> O S LETrEROFCREDIT =6 EXEMPRONW 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.❑ II ❑ III.❑ <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&SIGNED) OWNER'S TITLE <br /> PATE MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY ; <br /> COUNTY# <br /> JURISDICTION# FACILITY <br /> LOCATION C -OPTIONAL CENSUS TRACT* - �W 9UPVISOR-OISTA��CODE -LWTAONAI. )D/ 1 <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(393) OWNER MUST FILE THIS FORM W` 'HE LOCAL AGENCY IMPLEMENTING THE UNDERGROUNr SAGE TANK REGULATIONS <br />