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� 4YAITA C <br /> b� STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ., <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE £�4iroww'' <br /> MARK ONLY t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL <br /> ONE ITEM 72 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �l <br /> 1. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME. NAME OF OPERATOR <br /> ADDRES _,,V NEAREST CROSS STREET PARCEL N(OPTIONAL) <br /> CITY NAME STATE ` ZIP CODE SITE PHONE x WITH AREA CODE <br /> CA Ci su� " I�.2 i (I <br /> I/ BOX <br /> TO INDICTE CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCALAGENCY Q COUNTYAGENCY' STATE-AGENCY' 0 FFDERAL•AGENCY' <br /> DISTRICTS' <br /> If owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS t GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN x OF TANKS AT SITE E.P,A. I.D.x(aptionap <br /> RESERVATION <br /> 0 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS J <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal <br /> DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE <br /> —414 L <br /> NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE NIGHTS: NAME(LAST,FI S - PHONE x WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-JMUST BE COMPLETED <br /> NAME — CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET]ADDRESS ✓ box b Indicals = INDIVIDUAL 0 LOCAL-AGENCY 11 STATE-AGENCY <br /> - +Q`}U IyG d� -5 ffCORPORATION = PARTNERSHIP Q COUNTY-AGENCY L-1 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE x WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME Of OW ER CARE OF ADDRESS INFORMATION <br /> I SL'1v.1 � <br /> MAILING OR r�6 <br /> STREET ADDRESS ✓ box to indicate �] INDIVIDUAL LOCAL-AGENCY 0 STATE AGENCY <br /> .? - ,] ��^ti_ ,, =CORPORATION 0 PARTNERSHIP COUNTY-AGENCY [] FEDERAL-AGENCY <br /> CITY NAME STAT ZIP CODE PHONE x WITH AREA GO <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box Io indicate E-1 I SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BONO <br /> E] 5 LETTER OF CREDIT 6 EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal nolificalion and billing Will be sent to the tank owner unless box I or II is checked, <br /> F <br /> CK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. EL IMI. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY <br /> LOCATION CODE -OPTIONAL CENSUS TRACT x •OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FOAM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A113/93) 0 0 FOR/OWWR7 <br />