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tdW- f <br /> STATE OF CAUFORNIA - <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH F CILRYISITE `"�•�-"" <br /> MARK ONLY F-1 t NEW PERMIT Q 3 RENEWAL PERMIT Yf 5 CHANGE OF INFORMATION O T PERMANENTLY CL ITE <br /> ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT O 5 TEMPORARY SITE CLOSURE ©� <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> ORA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OFIIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> a CA I CI5yo5 <br /> ✓ Bo% CORPgUT10N 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY" ED FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS• <br /> •N oerwr of UST is a public agency,conplete the following:name W Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION L2 DISTRIBUTOR RESEIF INDIAN RVATION a OF T/AN�KS AT SITE E.P.A. I.D.#(op/ma) <br /> 3 FARM I� d PROCESSOR � OTHER OR TRUST LANDS L� <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: AME( ST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA LADE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> '31,23 <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NA CARE OF ADDRESS INFORMATION <br /> j.A <br /> MAILING OR STREET ADDRESS Q ✓ box bindbate 0 INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY <br /> O CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY 0 FEDEMLAGENCY <br /> CITY NAME STAZ.H I ZIP CODE P�'EX WITH ARE CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) L lll� 3 <br /> NAMEOFOWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bexbirdbale 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> O CORPORATION D PARTNERSHIP O COUNTYAGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- O I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ lbx biMkate 0 I SELF-INSURED 0 2 GUARANTEE 3 INSURANCE O X SURETY BOND <br /> 0 5 LETTEROFCREDIT 0 9 EXEMPTION O aS 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O IL III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED B SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY• rrtl z4r7 �31^ 323 2 5 CLQ <br /> LOCATION CODE -OiPTAONAL CENSUS TRACT#-OP77ONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> I <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORh&FI6N ONLY. <br /> FORM A(3'93) <br /> OWNER MUST FILE THIS WNS <br /> FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULAT � a•I I l e� <br /> Fglaro <br />