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V . �eeoo^ a oV <br /> STATE OF CALIFORNIA W <br /> ((JOSTATE WATER RESOURCES CONTROL BOARD w •' m <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ,n oe <br /> COMPLETE THIS FORM FOR EACH EAMrrYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F7 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE 57 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Flo r <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OFTIONAy <br /> a s� <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> S' CA I - ao9-I/ BOX <br /> G- 4r <br /> TO INDICATE D CORPORATION D INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY Q COUNTY AGENCY TATE AGENCY D FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION E] 2 DISTRIBUTOR / IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(oplianai) <br /> RESERVATION <br /> O 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS / <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> uA `s 206 -a <br /> NIGHTS: NAME( ST,FIRS <br /> PHONE WI THA EACODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDR SS INFORMATION <br /> C f3 /? NS l t;q Is <br /> MAILING OR STREET ADDRESS ✓ box binEiwte O INDIVIDU O LOCAL-AGENCYATE-AGENCY <br /> O' deoc o YrO CORPORATION O PARTNERSHIP COUNTY-AGENCY O FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> _ G4 � Save <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> ac.) e w s W_�- a 4v <br /> MAILING OR STREET ADDRESS ✓ box blMic le O INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION D PARTNERSHIP 0 COUNTY AGENCY FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4]-4]- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECOMPLETED)—IDENTIFYTHEME (S) USED <br /> %/ box Wndiwte O I SELF INSURED 2 GUARANTEE 3 INSURANCE I7 d SURETY BOND <br /> =5 LETTER OF CREDIT O 6 EXEMPTION = 99 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 checke <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAM E(PR INTED&S IGNATU RE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# $TOCic <br /> 3 % <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# OPTIONAL SUPVISOR-DISTRICT CODE OPTIONAL <br /> 0 3 jai PJ l( o <br /> THIS FORM MUST BE ACCOMPANIED YY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(591) FOROD33A5 <br />