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• STATE OF CALIFORNIA • <br /> p STATE WATER RESOURCES CONTROL BOARD <br /> ( ' UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ' <br /> � uo° <br /> MARK ONLY � NEW PERMIT <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> ❑ <br /> ONE ITEM ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION II�� <br /> ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT I_J PERMANENTLY CLOSED SITE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETE 6 TEMPORARY SITE CLOSURE <br /> R 9 <br /> DBA OR FACILITY NAME <br /> NAME OF OPERATOR <br /> ADDRESS S <br /> s� NEAREST CROSS STREET <br /> CITY NAME PARCEL N(OPTIONAL) <br /> STATE ZIP CODE _ <br /> `.A SITE PHONE,WITH AREA CODE <br /> TO INDICATE CORPORATION '� LN <br /> Q INDIVIDUAL PARTNERSHIP El LOCAL-AGENCY -------- _ <br /> TYPE OF BUSINESS DISTRICTS 0 COUNTYAGENCY C]STATE AGENCY FEDEPgLAGENCY <br /> ❑ i GAS STATION ❑ p DISTRIBUTOR <br /> ❑ 3 FARM ❑ ✓ INDIAN ,OF TANKS SITE E.P.p, L <br /> ❑ 4 PROCESSOR O 5 OTHER RESERR VATION <br /> EMERGENCY CONTACT PERSON (PRIMARY) OR TRUST LANDS <br /> DAYS: NAME(LAST,FIRST) EMERGENCY CONTACT PERSON (SECONDARY)- <br /> PHONE,WITHAREAC DE optional <br /> - r R S �� G k a.e. Z� DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) Z S <br /> PHONE,WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME <br /> OJpy 134,AS CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS �'CL C. <br /> CITY NAME Q CORPORATION t=INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> PARTNERSHIP Q COUNTYAGENCY Q FEDERAL-AGENCY <br /> 4-oSTATE ZIP CODE <br /> PHONE,WITH AREA COD•(MUST BE COMPLETED) <br /> III. TANK OWNER INFORMATION 3 b 25- 3� E <br /> � _ _Q <br /> NAME OF OWNER <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS• <br /> ✓box bindkale 0 INDIVIDUAL (] LOCAL-AGENCY L3 STATE-AGENCY <br /> CITY NAME - 0 CORPORATION 0 PARTNERSHIP <br /> STATE COUNry-AGENCY 0 FEDERAL-AGENCY <br /> ZIP CODE PHONE,WITH AREA CODE <br /> IV. BOARD OF EQUALI ST STORAGE FE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO [4X <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boxain0icalo 0 1 SELFINSURED <br /> C 5 LEITEROFCREDIT 1:31 2 GUARANTEE 1-13 INSURANCE <br /> Q 6 EXEMPTION O 59 OTHER 0 4 SURETY POND <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT IL <br /> Ln <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> APPLICANTS TITLE <br /> DATE MONTWDAY/VEAq <br /> LOCAL AGENCY USE ONLY <br /> COUNTY u JURISDICTION p <br /> L 9 �T� FACILITY u <br /> _ _ L S 6 2orog <br /> LOCATION CODE OPTIONAL CENSUSTRACT, - <br /> © / OPTIONAL SUPVISOR-DISTRICT COD>E -OP7/ONAL - <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 /> IPM A(12 81) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR003306 <br />