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• 0 6JJR <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETETHIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY � 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE / <br /> I. FACILITYISITE INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> DBAOR FACILI NA E NAME OF OPERATOR <br /> AD RESS - / NE6REST CROSS STREET y PARCEL#10WpNA0 <br /> CITY NAME 1{ SJTATE IP ODE SITE PHONE#WITH AREA CODE <br /> CA <br /> I/ BOX <br /> TO INDCATE D CORPO ON I�INDIVIDUAL l�PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY STATE AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS ST TION 0 2 DISTRIBUTOR O RESERVATION/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.x(optimal) <br /> O 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTLISP, <br /> ERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA G011P <br /> NIGHTS: NAME(LAST,FIRST) 1PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION-iM T BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box 0indkale INDIVIDUAL 0 LOCAL AGENCY 0 STATE AGENCY <br /> O CORPORATION 0 PARTNERSHIP COUNTY AGENCY O FEDERAL AGENCY <br /> CITY NAME - STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETE <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box Mkale 0INDIVIDUAL OLOCAL-AGENCY E3STATE-AGENCY <br /> CORPORATION D PARTNERSHIP O COUNTY-AGENCY D FEDEMLAGENCY <br /> CITY NAME N'\ <br /> ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER- all(916)323-9555 if questions arise. <br /> TY(TK) HQ F4141- <br /> V. <br /> 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—I NTIFY THE METHOD(S) USED <br /> ✓ box blMkata 0 I SELF INSURED 0 2 GUARANTEE <br /> O 0 3 IN <br /> 5 LET EROFCREgT O UflANCE A SU <br /> L�THER RETY ND <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: 1.0 II.❑ 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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> CODUNTNT�rYY# JURISDICTION# FA�CIILIT�Y�# <br /> LOCATION CODE/-OPTIONAL CENSUSTR -OPTIO AL SUPVISORDISTRICT CODE -OPTIONAL <br /> / # <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) //,I FOR0033A-5 <br />