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• • teooA e <br /> c <br /> STATE OF CALIFORNIA <br /> a <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETETHIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT n 3 RENEWAL PERMIT E_] 5 CHANGE OF INFORMATION n 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBAAO/OR FACILITY NAME NAMEOF OPERATOR II <br /> ADDRESS NEAREST CROSS STREET PAI(OPnONAU <br /> CITY NAME STATE <br /> CA 21P CODE I JG36SAREA <br /> Z 7i.6 <br /> LTO �INDICATE O CORPORATION [=1 INDIVIDUAL =PARTNERSHIP O LOCAL-AGENCY O COUNTY AGENCY 0 STATE-AGENCY O FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR RESERVATIONIF #OF TAr AT SITE E.P.A. I.D.#(optimal) <br /> O 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS I <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NA/M�E(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> //_ <br /> ,_ /� PHONE 8 WITH A13EA COOP <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING ADDRESS ✓ box blrQwale ED INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> v // Q CORPORATION E�j PARTNERSHIP [_1 COUNTY-AGENCY Q 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 RSTREETADDRESS ✓ box biMicate INDIVIDUAL O LOCAL'AGENCY LSTATE-AGENCY <br /> //• "t CORPORATION 0 PARTNERSHIP L] COUNTY AGENCY O FEDERALAGENCY <br /> CIIVNAME STATE ZIP CODE PH ONE WITH AREA CODE <br /> v <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ L��-[—F = <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Wxb indicate I� I SELF INSURED 2 GUARANTEE E] 3INSURANCE [_1 4 SURETY BOND <br /> 5 L27ER OF CREDIT O 6 EXEMPTION = 93 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.E] it.❑ III.E <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/VEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LL oozy <br /> LO� TRACT# OPTIONAL <br /> �ONCODE OPTIONAL CENSUSSUPVISORDISTRICTCODE -OPTIONAL . / <br /> 99Z Z3- / <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY <br /> FORM A(12.81) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOP <br /> 0 0 <br />