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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 FACILRY/SITE o^d .` �Z <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE <br /> `,(J <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> Vvy <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS 2NEAR EST CROSS STREET PARCEL#(OPTIONAL)' U <br /> CITY NAME <br /> STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> C.1 BXA <br /> TO INDICATE CORPORATION O INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY O COUNrY-AGENCY' D STATE-AGENCY' O FEDERAL-AGENCY'ownerd UST iso ub5ce op DISTRICTS <br /> D agency, late the lolbwin9:remads ervisord Grvisbn,iN.tbn or mwh oemba the UST <br /> TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR ✓IF INDIAN IN OF TANKS AT SITE E.P.A. I.D.It(optional) <br /> O 3 FARM ❑ 4 PROCESSOR 5 OTHER O RESERVATION <br /> ❑ 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#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COp4PLFTFD) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ (xxU n:w': O INDIVIDUAL 0 LOCAL-AGENCY <br /> (] O STATE-AGENCY <br /> CORPORATION <br /> f� PARTNERSHIP a COUNTYAGENCV =1 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF AUUHE55 INFORMATION <br /> MAILING OR STREET ADDRESS ✓ hoxtoegrale Q INDIVIDUAL O LOCAL-AGENCY <br /> O CORPORATION STATE AGENCY <br /> CITY NAME �PARTNERSHIP l�COUNTY-AGENCY =Q FEDEREOERALAGENCY <br /> STATE ZIP CODE PHONEq WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ [4—F4]- -� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box to IMkate I__1 1 SELF INSURED 0 2 GUARANTEE =3 INSURANCE =4 SURETY BOND Q 5 LEREROFCREDIT = 6 E%EMPTION L::)7 STATE FUND <br /> Q 8 STATE RIND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT 1 10 LOCAL GOVT.MECHANISM M 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will he 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.❑ it.❑ 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 MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY#3,;6 7 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> �7/,9 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS T IS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(6.95) OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDI ;6TORAGE TANK REGULATIONS <br />