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9 <br /> STATE OF CALIFORNIA ^`Sou'�r <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ~° <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE .o s id •° <br /> MARK ONLY ❑ 1 NEW PERMIT E:] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO-o^ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS 1 NEAREST CROSS STREET ' PARCEL#(OPTIONAL) <br /> 31 �. kms , f <br /> CITY NAME <br /> p — STATE ZIP DEQ - SITE PHONE p WITH AREA CODE <br /> CaBOX (a Caa�r t <br /> TO INDICATE CORPORATION INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' 0 STATE-AGBEY FEDERAL AGENCY' <br /> DISTRICTS <br /> H owner o/USTk a Dublk agetxy,campkte the f4lbwng:name d supervisord drvobn,seCbn or oKce which Polar,the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT .P.A. I.0.#(optional) <br /> ❑ RESERVATION <br /> "3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUSTLANDS SITE E <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFD) <br /> NAME ` CARE OF ADDRESS INFORMATION <br /> 8A I'lL)CIA <br /> MAILING OR STREET ADDRESS ✓ bcx to Q INDIVIDUAL <br /> ^dfa'a Q LOCAL-AGENCY O STATE AGENCY <br /> O CORPORATION O PARTNERSHIP 1= COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY AME /4STATE ZIPC E � PHONE WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) C <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxtovoirate E__1 INDIVIDUAL =1 LOCAL-AGENCY (] STATE-AGENCY <br /> CORPORATION O PARTNERSHIP O COUNTY-AGENCY FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-F4-1- <br /> V. <br /> 4- -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 0 1 SELF-INSURED O 2 GUARANTEE 1=3 INSURANCE Q 4 SURETYBOND =5 LETrEROFCREDIT O 6 EXEMPTION O 7 STATE FUND <br /> D B STATE FUND&CHIEF FINANCIAL OFFICER LETTER E�:]9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM ED 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: I.❑ II.❑ III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY kleC' t ( '�Ld (� <br /> COUNTY# JURISDICTION M FACILITY It <br /> E <br /> LOCATION CODE -OPTIONAL CENSUS TRACT.#.OPTIONALSUPVISOR-DISTRICT CODE -OP, <br /> jONAL' <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) OWNER MUST FILE THIS FOR&*THE LOCAL AGENCY IMPLEMENTING THE UNDERGROSTORAGE TANK REGULATIONS <br />