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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EA H FACILITYISITE <br /> MARK ONLY F7 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED T <br /> ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DB7,RFA FACILITY E _ N MEOFOPERATOR <br /> ADDRES r NE STCROSS TR ET PARCELS(OPTIONAW <br /> 112� <br /> PZ&e <br /> CITY E STATEZIP SITE PHONE a WITH AREA C9pE <br /> CA 5JG CC1l <br /> V, BOX <br /> TO INDICATE ED CORPORATioN E:] INDIVIDUAL [:3 PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY' O STATE-AGENCY' O FEOERAL#GENCY' <br /> N owner al UST is a public DISTRICTS <br /> p agency,mrrylele the following:name of SupervYor of tlivKbn,seclbn,or office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN IS OF TAN T SITE I E.P.A. I.D.a(whicnal) <br /> RESERVATION <br /> 0 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-apdonal <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NKINTS: NAME(IART.FIRST) PHONE a WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓OwbNtlksle INDIVIDUAL LOCAL-AGENCY if STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY O FEOEMLAGENCY <br /> STAT <br /> CITY NAME E ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓icor bYdkAM INDIVIDUAL LOCAL-.AGENCY 0 STATEAGENCY <br /> CORPORATION 11 PARTNERSHIP Q COUNTYAGENCY = FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a 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- -' <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓y�bbacr O t SELF-INSURED I]2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> D 5 LETTER OF CREDIT =&EXEMPTION Q m 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.Q II.= III.Q <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTIONS FACILITYS <br /> m wvj (� <br /> LOCATION -OPTIONAL CENSUS TRACT#- SUPVISGR-DISTRK;TCOO 77ONAL if y <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 FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) FOR0033AA7 <br />