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'O,,OVn [9 <br /> STATEOFCALIFORMA ,� �� <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE `���.eR+" <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E::] e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ✓ C <br /> ADDRESSNEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 7 -7 —7 L✓G vAc <br /> CITY NAME STATEZIP CODE 7E PHONE#WITH AREA CODE <br /> CA 9� Z�Z Zoa <br /> Box <br /> TOINDICATE O CORPORATION f INDIVIDUAL Q PARTNERSHIP. LOCAL-AGENCY f1 COUNTY-AGENCY' STATE-AGENCY' O FEDERAL-AWWY' <br /> DISTRICTS' <br /> N owner of UST Is a public agency,conplele the following:name of Supervisor of divibton,section,or office which operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RE/ IF INDIAN SERVATION #OF TANKS AT SITE E.P.A. I.D.#lbotianal) <br /> 3 FARM 4 PROCESSOR ❑ 5 OTHER 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 N WITH AREA CODE <br /> -.. , _ Z <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR SiTZEE T AD RESS I ✓bps blndkals 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION O PARTNERSHIP COUNTY-AGENCY (j FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING,OR STREET ADDRESS ✓ boa blMkab INDIVIDUAL ED LOCALAGENCY Q STATE-AGENCY <br /> ✓ O CORPORATION Q PARTNERSHIP [_1 COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CIT'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 44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boa beekale 0 I SELF INSURED 0 2 GUARANTEE (]3 INSURANCE 0 4 SURETY BONO <br /> D 5 LETTEROFCREDIT 6 ExEMPRON Q 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.❑ <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 MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> EH f <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OiPTIONAL SLIPVISOR-DISTRICT CODE -OPTIONAL <br /> V <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3''93) � . Fp10099A-197 <br />