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x60JR <br /> t <br /> n' <br /> STATE OF CALIFORWA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> O 1 NEW PERMIT � 3 RENEWAL PERMIT O 6 CHANGE OF INFORMATIONX7 PERMANENTLY CLOSED SITE <br /> MARK ONLY 5 t) <br /> ONE REM Q 2 INTERIM PERMIT � 4 AMENDED PERMIT � 6 TEMPORARY SITE CLOSUR <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BECOMPLETEDNAM) <br /> ro <br /> DBA OR FACILITY NAME N + ,�- <br /> NE TCROSSS REET IP CELN(OPTNINA11 <br /> ADDRESS <br /> CITY NAME <br /> `/ /+J STATE ZI DE_ / ITE PHO Es�VITH A@EA <br /> ✓ LOCAL-AGENCY O COUNTYdGENCY' O STATE-AGENCY'- E:l O F FEDERAL-AGENCY' <br /> Box <br /> TO INDICATE I�CORPORATION INDIVIDUAL E::] PARTNERSHIP <br /> 0 DISTRICTS' <br /> •N oener of UST Is a public agency,complete the following:name of Supervisor ol dNisio ,saction,or offloe which opiates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR Q ✓ I INDIAN NOF TANKS AT SITE E.P.A. I.D.a(aptianap <br /> RESERVATION <br /> O 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAM (LAST,FIR"yT) PHONE N WITH AREA CODE � ��NAE(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NUE(LIST,FIST)n <br /> PHONEa THARE CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> 11. PROPERTY OWNER TINr F/O✓R_M—A'TION- MUSTBE/CO/M�PLETED CARE OF ADDRESS INFORMATION <br /> bNAME 0i !,1 ,� ]/.•//���p� <br /> IN V fU�Y/A'f'(/G ✓ box IDIr&Ae 0 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> OR STREET ADDRESS ,G(�, CORPORATION PARTNERSHIP O COUNTY-AGENCY FEDEMLAGENCYSTC ZIP CyODEPHONEN WITH AREACODE <br /> E <br /> III, TANK OWNER INFORMATION (MUST BE COMPLETED) <br /> 7T�03 <br /> OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> MAILING OR STREET ADDRESS ox biMbale INDIVIDUAL OLOCAL-AGENCY 0STATE-AGENCY <br /> OflPolU170N PARTNERSHIP 0 COUMYAGENCY FEDEBALAGENCY <br /> E ZIP CODE PHONE0 WITH AREA CODE <br /> CITY NAME <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> Q t SELF-INSURED i1 2 GUARANTEE O 3 INSURANCE L <SURETY BONG <br /> ✓Om bin3kak 5 LETTER OFCREDIT 0 6 EXEMPTION 9e 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. Rl. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED 8 SIGNED) <br /> OWNER'STITLE DATE MONTHIDAVNEAR <br /> 4L 02 37 <br /> LOCAL AGENCY USE ONLY Iss <br /> COUNTY# JURISDICTION# FACILITY• <br /> LOCATION CODE .OPTION CENSUS TRACTi •OPTIONAL BUPVISOR-DL4TflICT CD,E -OPTION <br /> /J �? <br /> THISVORM 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 FOR0033A-R <br /> FORM A(393) <br /> c a41, <br />