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STATEOFCAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W d a a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A 5 i <br /> COMPLETE THIS FORM FOR EACH!30MISITE ear" <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY C OS�ED SITE 1 <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) / <br /> DBAOR FACILITY? E n-:0 NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL If(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> ��� �BOX �n CA SZ/ <br /> T NDICATE ]CORPORATION O INDIVIDUALARTNERSHIP O LOCAL-AGENCY 1]COUNTY-AGENCY' O STATE-AGENCY' O FEDERALAGENCY' <br /> DISTRICTS' <br /> If owner of UST Is a public agen Isle the following:name of Supervisor of o?felon,section,or office whbh operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTORQ ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.#(oplidrel) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY V AME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> V Z.i aA L �' 5���� <br /> NIGHT : NAME( T,FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST.FIRS T) PHONE#WITH AREA CODE <br /> 4'T'GJA _ 3 _ c .5C-5 <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME // CARE OF ADDRESS INFORMATION <br /> ✓ htiTf� <br /> MAILING OR STREET ADDRESS ✓ boabin6 cab = INDIVIDUAL O LOCAL-AGENCY ]STATE-AGENCY <br /> 315$ L G Y'h li L I]CORPORATION PARTNERSHIP 0 COUNTY-AGENCY ] FEDERAL-AGENCY <br /> CITY NAM �1 STATE ZIP CO E z� PHONE a WITH AREA CODE <br /> \TO✓ c/S <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bimcm I] INDIVIDUAL 1]LOCAL-AGENCY O STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP D COUNTYAGENCY ] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 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 4 Q 2 8 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boxbindimm ] 1 SELF-INSURED E—)2 GUARANTEE I]3 INSURANCE 0 4 SURETY BOND <br /> D 5 LETTEROFCREDIT 0 6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless bo r II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. if.L] III.E <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'STRLE DATE MONTWDAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# - <br /> ® I zb I I I61 <br /> LOCATION CODE -OPT/ONAL CENSUS TRACT# .OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> zz S_ ITHIS 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) 0 <br /> 0 <br /> FOR=3A.R7 <br />