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STATE OF CALIFORNIA i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �r <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY O t NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM r7 2 INTERIM PERMIT L:1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION$ADDRESS (MUST BE COMPLETED) <br /> DBA OR FACILITY NAM.E�-r ` NAME OF OPERATOR <br /> AQQBESS NEAREST CROSS STREET PARCEL X(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE X WITH AREA CODE <br /> CA <br /> I/ BOX <br /> TOINDICATE CORPORATION INDIVIDUAL I7 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' ED STATE-AGENCY' (] FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner of UST Is a public agency,complete the lollowing:narne of Supervisor of division,section,or office which Operates the UST <br /> TYPE OF BUSINESS [--i T GAS STATION 2 DISTRIBUTOR a ✓ IF INDIAN X OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal <br /> DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE NIGHTS' NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> 11, PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME _. � CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> r' C/ \�,r1� ! /\�✓ I=CORPORATION 0 PARTNERSHIP COUNTY-AGENCY ] FEDERAL-AGENCY <br /> CITY NAME 1 STATE ZIP CODE <br /> HONE WITH AREA CODE <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER / CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b indicate <br /> 0 INDIVIDUAL LOCAL-AGENCY ] STATE-AGENCY <br /> _ { <br /> t �, / ( ✓ /\ 14 CORPORATION 1 PARTNERSHIP [] COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE <br /> PHONE kWITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ 14F4- - = <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> J <br /> box to indicate Cl 1 SELF-INSURED 0 2 GUARANTEE I] 3 INSURANCE 0 4 SURETY BOND <br /> E-1 5 LETTERCFCREDT 0 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 /> FCHECKONE BOR INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L IL III,Q <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'STITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY <br /> 10 1 J, 5 1f <br /> LOCATION CODE -OPTIONAL CENSUS TRACT i -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 SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOAM A(3!931 � � RoPAo33AA7 <br />