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Y' <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD �, a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> / C�ti4NY•� <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY O I NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION PEP SED IT <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> (/ <br /> ADDRESS NEAREST CROSS STREET PARCEL((OPTIONAL) <br /> d 61,VP <br /> CITU NAME STACA ZIP CODE��(�/ SITE PHONE=WIT}IyREA CODE <br /> BOX <br /> TO INDICATECORPORATION 0 INDIVIDUAL C:D PARTNERSHIP C:3 LOCAL-AGENCY O COUNTY-AGENCY 0 STATE AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(Optional) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> A - 2 Z <br /> NIGH AME(LAST,FIRST) PH NE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE I WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ baa blAdicto D INDIVIDUAL Q LOCAL-AGENCY I1 STATE AGENCY <br /> Q CORPORATION = PARTNERSHIP O COUNTY-AGENCY (] 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 ✓ bot 0imcam Q INDIVIDUAL Q LOCAL-AGENCY O STATE-AGENCY <br /> (]CORPORATION PARTNERSHIP 0 COUNTY AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 T- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boo bimLau (] I SELF-INSURED 0 2 GUARANTEEQ 3 INSURANCE a SURETY BOND <br /> O 5 LETTER OF CREDT 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ it.O 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 NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRgOT+1•OPTIC SUPVISOR- FACT CGDE -OPTIONAL <br /> q Icy "J,f L Z -y2 <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 /> FORM A(5.91) <br /> \ ,� \ FOR0033A-5 <br />