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ttW^ f <br /> f <br /> STATEOFCAUFORNIA "f cti <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD � W nom' � n o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , o <br /> y COMPLETE THIS FORM FOR EACH FACILITY/SITE `'x�.ae+'' <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE Q <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME NAMED OPERATOR <br /> ADDRESS NEARESTCROSS STREET PARCEU(OPrIONAq <br /> i <br /> CITY NA E STATE ZIP CO SITE PHONE#WITH AREA CODE <br /> U, CA ,2kly <br /> TOINq ATE O CORPORATION I�INDIVIDUAL =PARTNERSHIP l� LOCAL-AGENCY O COUMYAGENCY' O STATE-AGENCY' O FEDEMLAGENCY' <br /> DISTRICTS' <br /> N owner of UST Is a public agency,complete the folrowing:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR 0 R.1 IF INDIAN <br /> #OF TANKS SITE E.P.A. I.D.#(g9Axwlo <br /> O 3 FARM 4 PROCESSOR 6 OTHER 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#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CAFE OF ADDRESS INFORMATION, I <br /> MAILING OR STREET ADDRESS ,^1 ✓Eoabirdbate = INDIVIDUAL O LOCAL AGENCY STATE AGENCY <br /> G ^VT) CORPORATION 0 PARTNERSHIP IBOUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATEI ZIP CODE PHONE#WITH AREA CODE <br /> L 4I <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER _ J CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box binekaeINDIVIDUAL LOCAL Q STA7bAGENCY <br /> 0 CORPORATION E_�] PARTNERSHIP COUNTY AGENCY 0 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 M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bat trinkets I SELFINSURED =2 GUARANTEE E::] 3 INSURANCE O A SURETY BOND <br /> O 5 LETTER OF CREDIT O 6 EXEMPTION =99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I of 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.0 I� III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED a SIGNED) OWNER'S TIRE DATE MONTHIDAWYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION S FACILITY 1 <br /> ELI <br /> LOCATION CODE -OPTIONAL CENSUS TRACT-OPTIONAL9UPVISOR-DISTRICT CODE -OPTIONAL <br /> 0 � ?;�L� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PER MR 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 /> FORM A(393) 0 <br /> FORD03ytg7 <br />