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coup e <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD `o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> G COMPLETE THIS FORM FOR FjQ FACILITY/SITE <br /> MARK ONLY NEW PERMIT j 3 RENEWAL PERMIT - 5 CHANGE OF INFORMATION O T PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT [:1 4 AMENDED PERMIT [1] 6 TEMPORARY SITE CLOSURE <br /> B <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> NAME OF OPERATOR <br /> ADDRESS <br /> NEAT rROSS STREET PARCEL p(OPTIONAL) <br /> CITY NAb1OE ` STATE/ ZIP CODE <br /> TE NEf AREA COpE <br /> ✓ <br /> CA <br /> aoz S�?7 <br /> TO INDICATE OgPJRATION 0 INDIVIDUAL I PARTNERSHIP O LOCAL-AGENCY E-I COUNTY-AGENCY �STATE-AGENCY <br /> DISTRICTS D FEDERAL-AGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.4(opt57a <br /> 3 FARM O 4 PROCESSOR 5 OTHER O RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DA/Y'S: NAtJE(LAST,FIRST) PHONE 4 WI I 1 AREA CODE DAYS: NAME(LAST,FIRST) <br /> y /TIN <br /> NIGHTS: NAME lLAST,FIRST) P E4 WITH ARIAWIDE NIGHTS: NAME(LAS FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME 7 CARE OF ADDRESS INFORMATION <br /> lidP� T,ev�[ -PA& I� . <br /> MAILING OR STREET ADDRESS ✓ bo rdkala O INDIVIDUAL <br /> 0 LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION � PARTNERSHIP Q COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CI U NAME <br /> /C>T- STATE ZIP CODEPHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION"(MUST BE COMPLETED) <br /> NAME OF OWNER �,/�• /// CARE OF AD DRESS INFORMATION <br /> MAILING OR STREET RESS• ✓ box to kale <br /> �• �� O O INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> CITY NAME' CORPORATION = PARTNERSHIP =1 COUNTY-AGENCY FEDERAL-AGENCY <br /> eTATEA ZIP CODE O <br /> PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER S-Y�Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY"(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box Nindicale L� I SELF-INSURED 0 2 GUARANTEE I= 3 INSURANCE <br /> U5 LETTEROFCREDIT O 6 EXEMPTION O 4 SURETY POND <br /> 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: <br /> I.� II.El 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) APPLICANTS TITLE <br /> DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# <br /> TRACT# FACILITY# <br /> _OCATION CODE OPTIONAL CENSUS -OPTIONAL ISOR-DISTRICT C <br /> ISUPVODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF E INF ATION ONLY. <br /> FORM A(12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGU <br /> FOROM3A R6 <br /> Y <br />