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2oUR [y <br /> STATE OF CALIFORNIA <br /> 9 <br /> STATE WATER RESOURCES CONTROL BOARDAL <br /> , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W <br /> Yn 7o r , C, <br /> /� CI CIIUX N� <br /> [//VY COMPLETE THIS FORM FOR EACH CILRYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT F7 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DRA OR FACILITY NA NAME OF OPERATOR <br /> ADDREAA r NEAREST CROSS STREET PARCEL#)OPTIONAL) <br /> CITY NAME STATE ZI CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> TOiNDIICCATE CORPORATION L_1 INDIVIDUAL L-1 PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR -" IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(oplional) <br /> RESERVATION <br /> F__j 3 FARM Q 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON {SECONDARY}-optional <br /> DA . NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME LAST,FIRST) <br /> Er JAICSG <br /> yONF tt WITH AREA COfli= <br /> ME(LAST,FIRST) <br /> o q t <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMCARE OF ADDRESS INFORMATION <br /> tr(, <br /> MAILING OR STREET ADDRESS ✓ box to indicate [] INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> S• 0 CORPORATION PARTNERSHIP 0 COUNTY-AGENCY [] FEDERAL-AGENCY <br /> CITY NAM STATE ZIP CODE PHONE#WITH REA CODE <br /> C a© <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP COUNtY-AGENCV O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 -FOA I'f 1 k1 91 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box tolndicate 1 SELF-INSURED =2 GUARANTEE 3 INSURANCE d SURETYBOND <br /> D 5 LETTER CF CREDIT 6 EXEMPTION 0 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> [CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 11. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHlDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF S FORMATION ONLY. <br /> FORM A{5-91) FCA-5 <br />