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n x a <br /> STATE OF CAUPoRMA STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION [_] 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY <br /> ONE ITEM ❑ 2 INTERIM PERMIT Q 4 AMENDED PERMIT ❑ B TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION& ADDRESS•(MUST BE COMPLETED) <br /> nRA ORF CILIVAME NAME OF OPERATOR <br /> G® �^ 01 PMLEI#IOP(OPTIONAL) <br /> ADDRES f S I NEAREST CROSS STREET <br /> 2 N S0.CYfPY', } <br /> CITY NAME STATE ZIP CODE 'j z L+ SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓ WX CORPORATION INDIVIDUAL PMTNFASHIP LOCAL-AGENCY �COUNTY-AGENCY' O STATE.AGENCY' �FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS' <br /> If owner at UST Is a public agency,mniplele the followbp:name of Supervisor of division,section.W oNles which operates the UST <br /> TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#ropllanal) <br /> ❑ ❑ RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR l� 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> F <br /> S: AME(LAST.FIRS HONi WI-TTH ARIA CGo E DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE-Q r, L3 PHONE a WITH AREA CODEHTS: NAME(LAS ,FIRST) ONE a WITH AREACADE NIGHTS: NAME(LAST,FIRST) <br /> v Y�Q <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME, P� CARE OF ADDRESS INFORMATION <br /> MAILINGORSTRfETADDRESS �� 936 ✓ box blydicaN INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 1� Cd ` QCORPORATION � PARTNERSHIP COUNTY AGENCY Q FEDERAL AGENCY <br /> CITY NAME 1� 1_—LG STATE ZIP CODEII� P ONE WITH AREA CODEZ�� <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Sa YA 2— <br /> MNLINGORSTREET ADDRESS ✓ botbinsimte 0INDIVIDUAL LOCAL-AGENCY Q STATE AGENCY <br /> O CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE is WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ F414-]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa bintlkau Ij<1 SELF INSURED 0 2 GUARANTEE 0 3 INSURANCE a SURETY BOND <br /> D 5 LETTER OF CREDIT 1=6 EXEMPTION =s3 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 /> ECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ H. <br /> CHH 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'S TITLE DATE MONTWDAV/YEAR <br /> M r. Eh\j S ,tom t" j <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 9UPVISOR-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 FOfl0033AR7 <br /> i FORM A(393) 0 <br /> • <br />