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• e' Ue <br /> ' , i <br /> w' <br /> STATE OF CALIFORNIA � -. 'b <br /> STATE WATER RESOURCES CONTROL BOARD w m,g s <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A . ., <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �"1e""�� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE AREA CODE <br /> CA <br /> T I/ BOX <br /> OCATE D CORPORATION INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY Ej COUNTY AGENCY' �STATE AGENCY' O FEDERAL <br /> DISTRICTS' <br /> If owner of UST Is a public agency,cooplete the following:name of Superuisor of division.section,or office which operates the UST <br /> IF INDIAN TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR RESERVATION <br /> NOF TANKS AT SITE E.P.A. I.0.#(pplimal) <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#WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE Y WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box blntlbale INDIVIDUAL (] LOCAL AGENCY Q STATE AGENCY <br /> O COflPoM ON O PARTNERSHIP O COUNTY AGENCY FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE if WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARL OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box biMbate O INDIVIDUAL O LOCAL AGENCY O STATE AGENCY <br /> CORPORATION O PARTNERSHIP [] COUNTY-AGENCY 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)322-9669 if questions arise. <br /> TY(TK) HQ F4]-4-]-[ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ Eox blMkale (] 1 SELF INSURED 2 GUARANTEE 3 INSURANCE (] 4 SURETY BOND <br /> = 5 LETTER OF CREDIT B EXEMPTION 0 W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or 11 its checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[—] 11-0 1 <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 a SIGNED) OWNER'S TITLE DATE MONTWDAYNFAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m Fm F—TT= <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,UNLESSTHIS IS ACHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THI LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0033A-197 <br /> FORM A(393) <br /> • <br />