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STATE OF CALIFORMA �� <br /> STATE WATER RESOURCES CONTROL BOARD W tl�, n a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A :� , <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE �C-4-OPM�� <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE — _- <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR ' <br /> ADDRESS NEAREST CROSS STREET PARCELO(OPTiONAL) <br /> CITY NAME STATE ZIP CODE SITEPHONE4 WITHAREACODE <br /> TOINDICATE O CORPoRAnON CD INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY �TwuNTYAGENCYSTATE-AGENCY• [-D FEDERAL-AGENCY' <br /> 'If owner of UST is aspent ublic y 9 DSTRICTS- <br /> p ,complete the following: of Supervisor of dNbbn,section,or office which operates the UST <br /> TYPE OF BUSINESS O t GAS STATION 2 DISTRIBUTOR ✓ESERVO <br /> IF INDIAN aOF TANKS AT SITE E.P.A. I.D.a(opiknal) <br /> ATIN <br /> 0 3 FARM 4 PROCESSOR Q 6 OTHER <br /> R <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME - CARE OF ADDRESS INFORMATION <br /> f <br /> MAILING OR STREETADDRESS `` ✓ box binAkate INDIVIDUAL 0 LOCAL-AGENCY O STATE AGENCY <br /> �',;: CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY = FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OFOWNER - CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESSl ✓ boa biMeals D INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION = PARTNERSHIP 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)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ ym bintlbate Q I SELF INSURED 0 2 GUARANTEE (]3 INSURANCE A SURETY BONG <br /> O 5 LETTEROFCREDIT 0 6 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.ET I.0- ILL <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF_F PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) __.T * F 'OWNER'S TITLE DATE IMONT AYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION# FACILITY C <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACTa -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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(3193) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> • FCe0033AR7 <br />