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oa p <br /> STATE OFCAUFORWA �< <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> . . o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM E:1 2 INTERIM PERMIT Q 4 AMENDED PERMIT E] e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA % ILIWE NAME OF OPERATOR <br /> AODRE S lq NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY N STATE ZIP coq � SITE PHONE#WITH AREA CODE <br /> CA N[ <br /> TO INDICATE O CORPORATION O INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCYSTATE-AGENCY' O FEDERAL AGENCY' <br /> -0 owner of UST Is a public agency,complete the following:name of Supervbor of ONu:ion,sectionDISTRICTS <br /> DISTRICTS'or office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR .1IF INDIAN 18 OF TANKS ATSITE I E.P.A. I.D.0 foutima(J <br /> 0 3 FARM Q 4 PROCESSOR 5 O OTHER RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-options[ <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• IMUS4 BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> ep <br /> MAI O TRE DRESS ✓box b6dbals (� DIVIDUAL (] LOCAL AGENCY ED STATE-AGENCY IIV <br /> O CORPORATION (1Yf PARTNERSHIP COUNTYAGENCY FEDEMLAGENCY <br /> CI A BT 4 ZIP PHONE M WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> N OF OW R CARE OF ADDRESS INFORMATION <br /> A I ORSTREPrADDRES ✓ hor biMbate 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION ARTNERSHIP lI COUMYAGENCY FEDERALAGENCY <br /> CITY NAME STATE ZIP PHONE#WITH AREA CODE <br /> c� 3 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 -WCL L <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bwbind.ta O 1 SELF-INSURED =2 GUARANTEE 3 INSURANCE <br /> d SURETY SONO <br /> O 5 LETTER OF CREgT =e EXEMPTION 91 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= II.[:j IN. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAM E(PR INTED&S IGNED) OWNER'S TITLE DATE MONTWDAY/VFAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUSTRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PER APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(SIBS) <br /> OWNER MUST FILE THIS FOR WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> • Fp77033AA7 <br />