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�� • STATE OF CALIFORNIA • - ��•oJ, <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> Yom ' O <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY I NEW PERMIT S RENEWAL PERMIT a 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED <br /> ONE REM 2 INTERIM PERMIT A AMENDED PERMIT e TEMPORARY SITE CLOSURE - <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBAOR FACILITY NAME A - ' NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL I(OPTIONAL) <br /> CITY NAME J STATE ZIP CODE SITE PHONE A WITH AREA CODE <br /> SZ� CA S�'La O <br /> I/ Box <br /> TO INDICATE Q CORPORATION Q INDIVOU.AL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY.AGENCY Q STATE-AGENCY Q FMCRAL-AGENCY <br /> DSTPoCTS <br /> TYPE OF BUSINESS a I GAS STATION 2 DISTRIBUTOR = <br /> RESERVATION <br /> IF iNOIAN <br /> s KS AT SITE )E.P.A L D.A(eptWW) <br /> Q S FARM C'I l PROCESSOR ti, 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) <br /> NIGHTS: NAME(LAST.FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> Pu <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> .VAIL,NG OR STREET ADDRESS ✓ EP[nAaieaM Q INOIVIOUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP LQ COUNTY-AGENCY Q FMERALAGENCY <br /> CITY NAME STATE ZIP CODE I PHONE A WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) ' <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ PPA OPIP[]Y Q INONIOUAL Q LOCAL-AGENGY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4-74 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ p yo Q I SELFNSURFD Q 2 GUARAKrEE Q S wSURANCE Q A SURETY BOxO <br /> Q <br /> $tETTEROFCRET Q 5 EXEMPTION Q N OTHER <br /> Vi. LEGAL NOTIFICATION AND BILLING ADDRESS Lega)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: L= IL Q IN.Q <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 A SIGNATURE) APPLICANTS TITLE DATE MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY Z <br /> COUNTY x JURISDICTION x FACILITY x <br /> Ill CflN17?�G = I G <br /> LOCATION CODE-/-OPTIONAL (CENSUS TRAC s rOAm SUPV 0R•D TCODE -OPnONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM Bt UNLESS THIS IS A CHANGE OF SITE NFORMATION ONLY. <br /> FORM A IS q FC/10617M5 <br /> -L•r{/'/ ��� �� <br /> ter- <br />