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• 'esoua es <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> sse <br /> COMPLETE THIS FORM FOR EACH ACILrTY/SITE `��n°nw• <br /> MARK ONLY 0 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT O d AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITYNAME NAME OF OPERATOR <br /> 75 11� 4 e <br /> ADDRESS NEAREST CROSS STREET PARCEL 9(OPTIONAL) <br /> a (? <br /> CITY NAME r _ STATE ZIP CODE SITE PHONE#WITH AREA-CODE <br /> G CA � c�3 <br /> T NDIICCATE CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY Q COUNTYAGENCY O STATEAGENCY <br /> DISTRICTS O FEDERAL-AGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKSAT SITE E.P.A. I.D.#(opfianal) <br /> RESERVATION <br /> 3 FARM O # PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DA S' NAME(LAST,FIRST)ire n PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> Cao sy <br /> NIGHTS: (LA a,FIR T) PHONE ITH AREA CODE- NIGHTS: NAME(LAST,FIRST) <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS oz bintlicale INDIVIDUAL <br /> ✓ bO LOCAL AGENCY STATE AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY EI] FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindkale O INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 14141- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boz In Indicate ID 1 SELF-INSURED 0 gyp NTEE 0 3 INSURANCE <br /> O 1 SURETY BOND <br /> O 5 LETTER OF CREDIT C&T EXEMPTION 0 99 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.El III.❑ <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) APPLICANT'S TITLE DATE MONTH/DAV/VEAR <br /> LOCAL AGENCY USE ONLY G E <br /> COUNTY# JURISDICTION# FACILITY#�`��—`������ <br /> 16CA-TIONCODE <br /> IONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CGDE -OPTIONAL - - <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF S I ORMATION ONLY. <br /> FORM A(5-91) ONLY. <br />