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FCC <br /> "1 STATE OF CALIFORNIA ^p a^ <br /> \\\ STATE WATER RESOURCES CONTROL BOARD i o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH CILRYISITE c�`�"°""" <br /> MARK ONLY ❑ x NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMAN ED S E • <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITYNAME <br /> \\ NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#I <br /> OPTIONAW <br /> CITY NAME I <br /> STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Wl� „1 c C, CA <br /> v Box <br /> TO INDICATE Q CORPORATIONDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY <br /> DISTRICTS Q COUNTY-AGENCY 11 STATE-AGENCY Q FEDERAL-AGENCY <br /> TYPE OF BUSINESS ❑ ! GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(opHonalJ <br /> 3 FARM O d PROCESSOR 5 OTHER O RESERVATION <br /> O OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) / HONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> oC �! i`Cchila � <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME oC C <br /> /� CARE OF ADDRESS INFORMATION <br /> /� �Y`chxb <br /> MAILING OR STREET ADDRESS ✓box to Indicate <br /> 3 Z 0O PARTNERSM UALHIP <br /> Q COUNTY <br /> ENCAGENCY <br /> O STATE-AGENCY <br /> CITU NAME C Q CORPORATION Q ppRTNERSHIP Q COUNTKAGENCV (] FEDERAL-AGENCY <br /> STAT ZIP CODE PHONE#WITH AREA CODE <br /> S' /l. Oih � <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> SGm QS CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRESS ✓ box bINIcele I I INDIVIDUAL <br /> Q <br /> CITY NAME Q LOCAL-AGENCY STATE AGENCY <br /> CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> 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) HO F4-T4-1- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box 0 indicate Q I SELFINSURED Q 2 GUARAMEE <br /> Q5 LETTER OF CREDT ED 3 INSURANCE d SURETY BOND <br /> Q 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 or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.E III.❑ <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 8 SIGNATURE) APPLICANT'S TITLE <br /> DATE MONTH7DAVNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACI hrr 3 <br /> Cm FTTI a yy <br /> LOCATION CODE -OP77ONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DIST ICT -OPTION <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE ITE��MATTI ONLY. <br /> FORM A(5-97) <br /> FOR0033/A/.5////A/ <br />