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0 <br /> STATE OF CALIFORWA <br /> STATEWATERESOU <br /> RRCESCONTROLBOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A a- <br /> COMPLETETHIS FORM FOR EACHFACILITYISITE <br /> ❑ 3 RENEWAL PERMIT ED CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY ❑ I NEW PERMIT S TEMPORARY SITE CLOSURE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ <br /> I. FACILITY/SITE INFORMATION&ADDRESS (MUST BE COMPLETED) <br /> OFOPERATOR _ � <br /> ppFACILI PARCEL%IOPfpNAL) <br /> / <br /> AANEAJioSTinOn3.43T Ej <br /> DD SiJ � �'y UGvv✓/ KF1T <br /> U� STATE ZIP CO E SITE PNONE%WITH AREA CODE <br /> CITY CA <br /> LOCAL-AGENCY 0 COUNTY-AGENCYCD STATE-AGENCY' C7 FWERALAGENCY' <br /> ✓ X 0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP DISTRICTS' <br /> TOINDICATE <br /> • ates the UST <br /> N owner d USE is a public agency.cumPlele the following:name of Supervreor of dNisbn,sectbn,or ogia whb�apF INDIAN NOF TANKS T SITE E.P.A. L D.%(gNlanaQ <br /> TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR - 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•OPtlenal <br /> PHONE%WITH AREA CODE <br /> DAYS: NAME(LAST.FIRST) PHONE%WITH AREA CODE <br /> DAYS: NAME(LAST.FIRST) <br /> PHONE%WITH AREA CODE NIGHTS:NAME(LAST.FIRST) <br /> PHONE%WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME <br /> ✓ box to 0 INDIVIDUAL OLOCAL-AGENCY �STATE-AGENCY <br /> MAILING OR STREET ADDRESS �]CORPOMTION O PARTNFAS.. 0 COUNTY-AGENCY �] FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE%WITH AREA CODE <br /> CITY NAME <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> ✓ hst biMbue INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> MAILING OR STREET ADDRESS 000RPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDEPAL-AGENCY <br /> STATE ZIP CODE IPHONE%WITH AREA CODE <br /> CITY NAME <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - —� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODES) USEDJINSURANC04 SUREIY eDND <br /> 0 1 SELFdNSURED O 2 GUARANTEE 0 S9 OTHER <br /> ✓ box biMk#e 0 5 LETTER OF CRE0IT 0 6 EXEMPTION <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box Ii rOs Checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IDSA UE AND <br /> aNC H� <br /> RECT <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY <br /> /DA HEAR <br /> OWNER'S TITLE <br /> OWNER'S NAME(PRINTED A GIGNED) ,/ <br /> LOCAL AGENCY USE ONLY FACILITY#ml ^/ �(y <br /> COUNTY# JURISDICTION# SIF J <br /> FLOC-ATIOVTE -OPTIONAL CENSUS TRA 40.4 <br /> 9lN>VISOR•DISTRICT CODE'-2V. <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS ACHANGE OF SITE INFORMATION ONL' <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGETANK REG ULA7?QNSFr <br /> FORM A(393) a0/ <br />