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- <br /> a <br /> Y <br /> STATE OFCAUFORNIA STATEWATER RESOURCES CONTROL BOARDND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EAC A/ACILRYISITE <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT arfi CHANGE OF INFORMATION MANSENT).Y CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT 4 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE C (� <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACIL TY tiAME� NAME PERAPO.. / ` <br /> ADOR 5 G NEAR CROSS STREET IT PARCEL+(OPfpNAL) C <br /> l�C <br /> CITY NAVEr-, STATE ZIP CODE SITE PHONE i WITH Afl <br /> cam\ CA 1 <br /> TOI/ BOX <br /> INDICATE CORPORATION Q INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY Q COUNTYAGENCy' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> '11 owner d UST is a public agency,comime the following:name of Supewisar of diviaion.section,m office whbh o atea the UST <br /> TYPE OF BUSINESS I GAS STATION Q 2 DISTRIBUTOR Q RE/ IF INNDIAAN 0 O TANKS AT SITE E.P.A 1.0.0 tept"W) <br /> ON <br /> 3 FARM Q 4 PROCESSOR Q 5 OTHER ORTRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCT CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.IT <br /> PHONE WITH AREA CODE DAYS: NAME(LAST.FIRST( PHONE WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIR PHONE+WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE WITH AREA CODE <br /> II. PROPERTY OWNER I ORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ EmbwicaY Q INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION O PARTNERSHIP Q UNTYdGENCY D FEDERALAGENCY <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 ✓ Emuinsbab C:] INDIVIDUAL LOCAL-AGENCY \—Q STATE-AGENCY <br /> \ CORPORATION Q PARTNERSHIP O COUNTYAGENCY 'L_J FEDERN.-AGENCY <br /> CITY NAME \ STATE ZIP CODE PHONE+WITH AREA\E <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. \ <br /> TY(TK) HQ F4-F4--]- E Q \\ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ lbs 0 wicale O I SELF-INSURED a 2 GUARANTEE 0 1 INSURANCE A SURETY BOND <br /> O 5 LETTEROFCREDIT 0 6 ExEmpnoN 99 OTHER �{/ Fell-11— <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.O Il.[—] III.E <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(PRINTED 6 SIGNED) OWNER'S TITLE DATE MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY ! <br /> COUNTY# JURISDICTION# A ILrTY# <br /> LOCATION CQOE -OPTIONAL CENSUS TRACT+ -OP NAL SUPVISOR-OLSTRIOT CODE -OP NAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESSTHIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FOFqr THE LOCAL AGENCY IMPLEMENTING THE UNDERGR(=STORAGE TANK REGULATIONS <br /> FORM A(WIG) c FCADWMAT <br /> I <br />