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• 0 <br /> STATE OF CALIFORNIA .rte ` <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A �� <br /> o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE c�„a,,,n�' <br /> MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ y AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE <br /> I <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME NAME OF OPERATOR <br /> T rT <br /> ADDRESS <br /> NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME <br /> STATE ZIP CODE CA SITE PHONE#WITH AREA CODE <br /> 95Z�Z <br /> TO Aox <br /> C TE Q CORPORATION Q INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE AGENCY Q FEDERAL-AGENCY- <br /> If Owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or Of ico which Operates the UST <br /> TYPE OF BUSINESS O t GAS STATION ❑ 2 DISTRIBUTOfl ✓ IF INDIAN #OF SE <br /> ITE E.P.A. I.D.#fopla sq) <br /> Q 3 FARM O A PROCESSOR 5 OTHER O RESERVATION TANKS AT <br /> 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) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS <br /> IGHT S: NAME(LAST.FIRST) PHONE#WITHAREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> M �gSTREET ADDRESS ✓EorblMkaleQ LOCAL-AGENCV Q STATE-AGENCY <br /> a Q INDIVIDUAL <br /> CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Eos bintlkaN Q INDIVIDUAL Q LOCALAGENCY <br /> Q STATE-AGENCY <br /> Q CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> SZ� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bOebiMkate (] I SELF-INSURED Q 2GUARANTEE <br /> Q T Q 3 INSURANCE O<SURETY BOND <br /> 5 LETrEROFCREg <br /> Q 8 EXEMPTION Q 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 checked. <br /> CHECKONE 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 <br /> OWNER'S NAME IF R INTED&S IGNED) OWNER'S TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# _ <br /> LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> Z ?zz� <br /> OR MORE PERMIT APPLICATIO <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1) N- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(393) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> • It <br /> FORc073AT17 <br />