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STATE OF CALIFORNIA w`n� <br /> STATE WATER RESOURCES CONTROL BOARD coM1 o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� ep <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE •e �,.re <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED.SITE <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 /> i <br /> ADDRESS NEAREST CROSS STREET P L#(OPTIONAL) <br /> zvw <br /> CITY NAME STATE ZIP COffE SITE PHONE M WITH AREA CODE <br /> CA <br /> TOI BOOX 0 CORPORATION I�INDIVIDUAL f�PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' OSTATE-AGENCY' OFEDERAL-AGENCY' <br /> DISTRICTS <br /> 9 ovmerd USTbe publicagency, tame d SeWee4Sor d tlbbbn,sedbn oro6ice which operates the UST <br /> TYPEOFBUSINESS a IGASSTATION a 2DISTRIBUTOR IF INDIAN 1OFTANKS AT SITE E.P.A. I.D.#(optional) <br /> ❑ 3 FARM ❑ 4 PROCESSOR A <br /> 5 OTHER RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRS CPPPHO E#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NA (LA5T,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CAREOFADDRESS INFORMATION <br /> MAILING OR STREa ADDRESS ✓ box bb0Ca10 E�:]INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY <br /> (]CORPORATION O PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE LP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> =4 oKe <br /> MAILING OR STRE ADD SS ✓ boxtoi7xale Q INDIVIDUAL I=LOCAL-AGENCY O STATE-AGENCY <br /> [1:1 CORPORATION O PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITU NAME STATE ZIP <br /> PCCODE PHONE#WITH AREA CODE <br /> r' / <br /> — 9 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9469 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box Waojo to 1 SELF4NSURED O 2 GUARANTEE Q 31NSURANCE L-1 4 SURETYBOND = 5 LETTEROFCRm1T O 6 EXEMPTION = T STATEFUND <br /> 6 STATE RIND&CHIEF FINANCIAL OFFICER LETTER [—_19STATE FUND&CERTIRCATE OF DEPOSIT Q 10 LOCAL GOVT.MECHANISM O99 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 TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY If <br /> mks <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 4:7,7 <br /> .x <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 /> FORM A(6-95) OWNER MUST FILE THIS FORM.WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROWTORAGE TANK REGULATIONS <br />