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w <br /> STATE OF CAUFORNIA 'o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY t NEW PERMIT O 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOS <br /> ONE REM O 2 INTERIM PERMIT 0 4 AMENDED PI 176 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FA ILI NA E NAME OF OPERATOR <br /> ADDRESS NEA ESTCRO STREET PARCELN(OPTIONALI <br /> Is <br /> CITY NASTATE ZIP CODE SI PHONES ANN AREA CODE <br /> CA <br /> ✓ BOX 0 CORPORATION D INDIVIDUAL l�PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY- STATE-AGENCY' O FEDERAL <br /> TO INDICATE DISTRICTS' <br /> If owner of UST Is a public agency,complete the following:name of Supervisor of d"bn.section,or office which operates the UST <br /> / IF INDIAN 1TYPE OF BUSINESS 0 1 GAS STATION 2 DISTRIBUTOR O q SERVATTION NOF TANKS AT SITE E.P.A. I.D.N(optional) <br /> 0 3 FARM Q 4 PROCESSOR O 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 N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM / CARE OF ADDRESS INFORMATION <br /> Id <br /> MAILING OR St <br /> DRE G ✓boz bintlkate 114, <br /> INDIVIDUAL LOCAL O STATE-AGENCY <br /> CORPORATION O PARTNERSHIP COUNTYAGENCY O FEDERAL <br /> CITY NAME STATE„ 21P ODE PHONE#W H AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING ORSTIR ET AOD SS ✓ box 0im.ate INDIVIDUAL O LOCAL O STATE AGENCY <br /> CORPORATION PARTNERSHIP 0 COUNTY AGENCY D FEDERAL AGENCY <br /> CITY NAM ' 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 4 4 Q <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box binEkale l= f SELF-INSURED 0 2 GUARANTEE = 3 INSURANCE 7-14 SURETY BOND <br /> I= 5 LETTEROFCREDIT I=S EXEMPTION w 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. III. <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 —17=EAR <br /> LOCAL AGENCY USE ONLY ID <br /> COUNTY# JURISDK:TION# RY# r7- <br /> [� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 3UPVISORT DISTRICT -OPTA7NAL <br /> o r a a s o vI I �0 <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 REGULATIOW FORDi a7 <br /> FORM A(393) 0 <br /> 0 <br />