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yW f <br /> • STATE OF CAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A g, ' <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE I <br /> I <br /> I I I NkW PERMIT a D RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SIT <br /> MARK ONLY rJ _ (�p <br /> ONE REM I._.� ] INTERIM PERMIT / AMENDED PERMIT 8 TEMPORARY SITE CLOSURE l <br /> I. FACILI TYISITE INFORMATION S ADDRESS-(MUST BE COMPLETED) <br /> NAME OF OPERATOR <br /> DBA OR FACILITY NAMk <br /> - NEAREST CROSS STREET PMCEII(OPrgNAU <br /> ADDRESS C OL <br /> CITU NAME J STATE ZIP CODE SITE PHONE A WITH AREA CODE <br /> CA <br /> ✓ Boz c(AInpMION Q Wa'YIOUAL Q PARTNERSHP Q LOCAL AGENCY <br /> Q COVNTYAGENCY' Q STATE AGENCY' Q FEDERAL AGENCY' <br /> TO INDICATEolre ute ft,@ w''S:� d SoperYkor d UNkbn.taction,w odioe which operateA the UST <br /> 'downer al UST Is.pWso NerwY,'r" <br /> TYPE OF BUSINESS O I OAd dIAT10N Q 2 DISTRIBUTOR Q SERV <br /> REATDIIAN <br /> ON SOF TANKS AT SITE E.P.A. I.D.S(nprana1J <br /> J FAPM • PROCESSOR 5 OTHER OR TRUST LANDS r <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-opilonel <br /> PFgNE S <br /> DAYS: NAME(LAST.FIRST WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE S WITH AREA CODE <br /> �q _ -7&6 PHONES WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE S WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRS 11 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> G/ / ! _(_ ✓ deab WbaM <br /> �QQ 6 Q INDIVIDUAL Q LOCAL AGENCY Q STATE AGENCY <br /> MALWG OR STREET AOOFIESS Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY FEDERAL <br /> AGENCY <br /> STATE ZIP CODE PHONE i WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> C�- ✓ [Or bYtlbAN <br /> MAILING OR STREET AODR40 Q INDIVIDUAL Q LOCAL AGENCY Q STATE AGENCY <br /> O O� o o Q CORPORATION Q PARTNERSHIP Q COUNTY AGENCY Q FEDERAL AGENCY <br /> S'TATAE ZIP CODE PHONE S WITH AREA CODE <br /> CITY NAME E� <br /> -2� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ Cf4_1"I 1� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> Q 1 SELF INSURED Q 2 GUARANTEE Q O INSURANCE Q A SURETY BOND <br /> '� OoA bY�cr Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q W 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 NOICATINO WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[�j 11. III.❑ <br /> THIS FOAM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OW NERSNAMEWRWTEDA SIGNED) OWNERS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUN TY r JURISDICTION• <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL9UPVISOR-DISTRICT CODE -OP <br /> o z3. 5zD <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 <br /> FORM A 06" FtlLom1AA7 <br />