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0 0 w• ea <br /> STATE OF CALIFORNIA c'� <br /> STATE WATER RESOURCES CONTROL BOARD ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION " FORM A ';tl <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE `n�.Pa+'' <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 1W 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO SI <br /> ONE REM Q 2 INTERIM PERMIT Q 0 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> nPA OR FACILITY NAME NAME OF OPERAT R <br /> S <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 5 IAJ. t L.t t <br /> CITY E STATE ZIP CODE SITE PHONE s WITH AREA CODE <br /> c la CA q 3 <br /> ✓ BOX CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE AGENCY' Q FEDERAL AGENCY <br /> TOINdCAIE DISTRICTS• <br /> If owner of UST Is a public agency,complete the following:nan a of Supervisor of limon,section,w office which operate;the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR RESERVATION <br /> / IF INDIAN <br /> a OF TANKS AT SITE E.P.A. L D.a lapdonap <br /> 0 3 FARM Q A PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal <br /> DA S: NAME(LAST,FIR PHONE#WITH AREA CODEDAY ' NAME(LAST,FI T) PHONE i WITH AREA CODE <br /> _ J <br /> NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME LKST,FIRST) PHONE a WITH AREA CODE <br /> H. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAM C4 JE CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET[t0DRE55 ✓ bosbiMkaN Q INDIVIDUAL Q LOCALAGENCY Q STATE AGENCY <br /> 8 Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNERCARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa biMbas Q INDIVIDUAL Q LOCAL AGENCY <br /> Q STATEAGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HQ r44V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa bvtlkale Q I SELF-INSURED 0 2 GUARANTEE Q 3 INSURANCE Q A SURETY BOND <br /> 0 5 LETTER OF CREDIT 0 6 E%EMPnON 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.= it.❑ III. <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 B SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTIONS FACILITY s q q(0 `� <br /> ® 2 Ir7lQin <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -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 /> FORMA(3(93) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATK NS Fish <br />