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STATE OF CALIFORNIA o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A R, <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT [_] 5 CHANGE OF INFORMATION O T PERMANENTLY CL SITE <br /> ONE REM 2 INTERIM PERMIT Q 4 AMENDED PERMIT S2 S TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS ����,�••-•�� NEAREST CROSS STREET PARCEL a(OPfIONAu <br /> CITY t{AME4/ ST CA ZI�C SITE PHONE 0 WITH AREA CODE <br /> T NI BoxgCATE O CORPORATION INDIVIDUAL PARTNERSHIP f�PARTNERSHIP ODISTRCTGFNCY CWNry-AGEUNCV' OSTATE-AGENCY' OFEDERAL-AGENCY' <br /> 'ff owner of UST Is a public agency,mwide the following:name A Supervisor of dhdsbn,section,or office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR q I/ IF INDIAN i <br /> SERVATTION A OF TANKS AT SITI E.P.A. I.D.i(apIvW) <br /> 0 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NKiHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME GQ ' CARE OF ADDRESS INFORMATION <br /> MAILI OR STREET ADDRESS Wak,mmaN O INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> • O D CORPORATION O PARTNERSMP D COUNTY-AGENCY D FEDERAL AGENCY <br /> CITY NAME STATE ZIP�V P ON I�WIT AREA IE <br /> lo <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> EG- !4s Co <br /> MAIL�I6 OR STREET ADDRESS ✓ bUbinEbah, INDIVIDUAL O LOCAL O STATE-AGENCY <br /> J �• 7� O CORPORATION 0 PARTNERSHIP =COUNTY-AGENCY E71 FEDEMLAGENCY <br /> CITU A�� STgTE -7 <br /> ZIP60DEI RHONE N H AREA CO E <br /> zz <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 /> ✓ boa blo icato 0 1 SELF-INSURED ED 2 GUARANTEE L_�] 3 INSURANCE IJ a SURETY BOND <br /> 0 5 LETIEROFCREDIT ED 6 EXEMPTION 0 W OTHER <br /> Vl. 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.O II. III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORREC <br /> OWNER'S NAME(PRINTED a SIGNED) OWNER'S TITLE DATE MONTHNAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY star <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OP770AWL SU R-DISTRICT CODE -OPTIONAL <br /> Lt/' 6 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3N3) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />