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a <br /> STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY T NEW PERMIT 3 RENEWAL PERMIT [ CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED R <br /> $ S <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DB;? p T NAME v NAMEOFOPERATOR <br /> ADDRESS Y N NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> Z12Kf� ,C CODE oos- <br /> CI NAME STATE ZIP SITE PHONE#WITH AREA CODE <br /> Ar-AAA;, CA q Z zv <br /> TO INDICATE D CORPORATION 0 INDIVIOUAL 0 PARTNERSHIP LOCAL-AGENCY (] COUNTY-AGENCY O STATE-AGENCY 0 FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 3 GAS STATION O 2 DISTRIBUTOR O -- IF INDIAN IN OF TANKS AT SITE E.P.A. I.D.x(optimal) <br /> RESERVATION O <br /> '.(FARM O 4 PROCESSOR E--] 5 OTHER 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) PHONE x WITH AREA CODE NIGHTS: NAME(LAST.FIRST) t WITH AREA mnp <br /> WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMECARE OF ADDRESS INFORMATION <br /> ��*Q eW <br /> MAILING OR STREET ADDRESS ✓ lna bintllraN INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> ` CORPORATION 0 PARTNERSHIP Q COUNrYAGENCY FEDERAL-AGENCY <br /> CITY;; STATE ZIP CODE -/ PHONE N WITH AREA CODE <br /> JL h2�lV <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> «le <br /> MAILING OR STREET ADDRESS <br /> / ✓WxbindkaW INDIVIDUAL Q LOCAL-AGENCY 0 STATE-AGENCY <br /> �D�Et Q CORPORATION (] PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CI MESTATE� 9Ci U <br /> ZIP CODE PHONE#WITH AREA CODE <br /> /yam fiZ <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. <br /> TY(TK) HQ 4 4 Q Z Z <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Cm bindkaN 0 T SELF-INSURED 0 2 GUARANTEE E--1 3 INSURANCE O 4 SURETY BOND <br /> 5 LETTER OF CREDIT 0 6 EXEMPTION THER <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.0 <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 TIRE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> f � <br /> LOCATION CODE -OPTIONAL CENSU�TRACT8 -OPTIONAL S P ISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(591) FOR0033A5 <br /> 1111d <br />