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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> o..,. <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F—] 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT O 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACRITYNAME /y NAME OF OPERATOR <br /> rVI �V an/'C. <br /> ADORESS NEAREST CROSS STREET PMCEL#(OPTK)NAM <br /> CITY NAME STATE ZIP CODE TE PHO #WITH AREA CODE <br /> �A as - a�s <br /> Lo dt� <br /> ✓ BOX <br /> TOINDICATE 0 CORPORATIONINDIVIDUAL D PARTNERSHIP O LOCAL-AGENCY ll COUNTY-AGENCY (]STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O T GAS STATION Q 2 DISTRIBUTOR I O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(OPUM.1) <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION <br /> O OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PN#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE 4 WITH AREA C0111 <br /> II. PROPERTY OWNER INFORMATION• MUS BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa b Wicala INDIVIDUAL LOCAL AGENCY Q STATEAGENCY <br /> O CORPORATION PARTNERSHIP Q COUNTY-AGENCY l= FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION'(MUST BE COMPL ED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box 0 wk:ab [_1 INDIVIDUAL OLOCAL-AGENCY L-1 STATE-AGENCY <br /> 0 CORPORATION Q PARTNERSHIP O COUNTY-AGENCY E-1 FEDERALAGENCY <br /> CITY NAME- STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT UMBER-Call(916)323-9555 it questions arise. <br /> TY(TK) HO 4 4 -Q- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BEC PLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa biMicaN 0 I SELF INSURED C-'2 GUARANTEE 0 3 INSURANCE 4 SURETY BONG <br /> O 5 LETTEROFCREDIT 6 EXEMPTION O W 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: L II.O HE O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE - TIONAL ICENSUS TRACT# -OPTIO L SUPVISOR DISTR CT 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(12-SI) FILE THIS FORM WIT HE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0033Ag6 <br />