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• 0 .oun <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD • , : 'o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> onr' <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ] PERMANENTLY CLOSED SITE <br /> ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT E—] e TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) V <br /> DBA F CILITY NAME NAME OF OPERATOR <br /> A7DD / /� N R TC?OSTR? <br /> PARCEL#(OPTIONAL) <br /> op <br /> -CI NAME � STATE CODSITE PHONE#WITH AREA CODE <br /> 77 Vek7*11 CACi/ <br /> Box <br /> TOINOICATE IM CORPORATION Q INDIVIDUAL O PARTNERSHIP (] LOCAL-AGENCY O COUNTY-AGENCY E�:)STATE-AGENCY 0 FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN 4 OF TA 5 AT SITE E.P.A. I.D.#(optimal) <br /> ❑ 3 FARM ❑ 4 PROCESSOR RESERVATION <br /> 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) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxbirdicats = INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> TF1 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bintlbate INDIVIDUAL = LOCAL-AGENCY M STATE-AGENCY <br /> O CORPORATION PARTNERSHIP 0 COUNTY-AGENCY M 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 F4-1-41- V VI-7- ✓I U-L7J <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMP ED)—IDENTIFY THE METHODS) USED <br /> ✓ box bindicate = 1 SELF INSURED =2 ARANTEE O 3 INSURANCE D A SURETY BOND <br /> O 5 LETTER OF CREDIT JI EXEMPTION N 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.❑ 111.❑ <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 A SIGNATURE) APPLICANT'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTYM] �� / JURISp�IC71pryg FACILITY# n <br /> LOCATION COO - PTIONAL CENSUS TRACT TIO,p)1LT SUPVISOR-DI T ICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGEPF SITE INFORMATION ONLY. <br /> '1RMA(5-eT) FOR00 A5 <br />