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• STATE OF CALIFORNIA • <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> O <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OP TIONAL) <br /> 'Sept, !� <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> r 6 CA "'75W c7 <br /> ✓BOX O CORPORATION 0 INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY' 0 STATE.AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> I ownerol UST is a public agency,=plate the blowing:n o olsupoMsorddNision,wiDnora#icewhichopemtastha UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR Q RESERVATION✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.X(optional) <br /> 1 3 FARM Q 4 PROCESSOR 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) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME clCARE OF ADDRESS INFORMATION <br /> �Y �- 7 <br /> MAILING OR STREET ADDRESS ✓ boebeMw•ale 0INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> #f&7I 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> v� G4 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNEflT}�� � ,,��•" �y CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS /� ✓ box h itdirale O INDIVIDUAL 0 LOGAL-AGENCY 0 STATE-AGENCY <br /> O ) Lo/�lA 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE X WITH AREA CODE <br /> Gq 9 S 2s <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 /> ✓box 10,r .ale O 1 SELF INSURED 0 2 GUARANTEE O 3 INSURANCE 0 4 SURETY BOND O 5 LETTER OFCREDIT O 6 EXEMPTION O 7 STATE RIND <br /> D 6 STATE RIND E CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND&CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM 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: 1.❑ 11.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHYDAY9EAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# v_ <br /> Z"JL/Ao <br /> LOCATION CODE-OPTIONAL CENSUSTRACT# -OPTIONAL SUPVVIIISSOR-DISTRICT CODE -OPTIONAL <br /> d Z3. 7� <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 /> FORMA(6-95) <br /> OWNER MUST FILE THIS FOR jr THE LOCAL AGENCY IMPLEMENTING THE UNDERGROIWRAGE TANK REGULATIONS <br /> ' <br />