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• • ebW- O <br /> STATEOFCAUFORMA <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A :- o <br /> n . <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `��•a-+" <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLO917E <br /> ONE REM F--12 INTERIM PERMIT Q 4 AMENDED PERMIT 06 TEMPORARY SITE CLOSURE /Z3 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) I D b <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> :2*iL <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY ME STATE ZIP CODE SITE RHONE s WITH AREA CODE <br /> CA q D ^>o <br /> TO INDICATE RTE r�PORATION 0 INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY 0 comy-AGENCY' 0 STATE-AGENCY' O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner d UST Is a public agency,mmplela the following:name of Supervisor of division,sectian,W Once which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR RESERVATTION- IF INDIAN #OF TANKS AT SITE E.P.A I.D.#(nplbTal) <br /> 3 FARM E__] 4 PROCESSOR W5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS:PAME(LASTJ FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> v4? - � <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> lid/ v woe <br /> MAILING OR STREET ADDRESS ✓boa bindbaoa O INDIVIDUAL 0 LOCAL 11 STATE-AGENCY <br /> Q C� lj j CORPORATION 0 PARTNERSHIP O COUNTYAGENCY 0 FEDERALAGENCY <br /> CITY NAME STATE ZIP CODEPHONE# ITH AREA CODE <br /> Goa GQ q 1 _ Q <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boatliMiGU 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> ,7G; <br /> , CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY 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 /> ✓boa b Indicate 0 1 SELF INSURED [--]2 GUARANTEE O 3 INSURANCE 0 1 SURETY BOND <br /> 0 5 LETTEROFCREDIT O 6 EXEMPTION 0 79 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.D II.❑ III. <br /> T141S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TRLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY• <br /> m ✓ � <br /> rJ <br /> L fIDN CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> _ a3•�b �- <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PER; APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE II'FORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(393) � � FixR6W3M7 <br />