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• STATE OF CALIFORNIA • 0 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> / UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYll <br /> EARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT <br /> ONE ITEM ❑ 2 INTERIM PERMIT LLI 5 CHANGE OF INFORMATION Y-� <br /> ❑ < AMENDED PERMIT Y-� T PERMANENTLY CLOSED SITE <br /> I. FACILITY/SITE INFORMATION$ADDRESS-(MUST BE COMPLET e TEMPORARY gl�CLOSURE n <br /> DBA OR FAC ITY NAME Ja <br /> ACORESS � � Ill NAME OF OPERATOR <br /> CITY NAME <br /> 5• pills 1 NEAREST CROSS STREET PARCEL#(OPTIONAL)'�}�I� I b \,j�`' STATE ZIP CODE <br /> ,/ BoxS' <br /> TOINCA SITE PHONE A WITH AREA CODE <br /> INDICATE Q CORPORATION INDIVIDUAL <br /> 0 PARTNERSHIP [:I LOCA <br /> O gIAGENCY Il COUNTY-AGENCY Q STATE-AGENCY O FEDERALAGENCY <br /> TYPE OF BUSINESS E] 1 GAS STATION ❑ 2 DISTRIBUTOR <br /> CTS <br /> ❑ 3 FARM ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I D p/opllgTy) <br /> ❑ 4 PROCESSOR 5 OTHER RESERVATION <br /> C::] <br /> oRTRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> DAYS: NAME(LAST,FIRST) EMERGENCY CONTACT PERSON (SECONDARY) <br /> PHONE A WITH AREA CODE <br /> GAYS; NAME(LAST,FIRST) ) Optional <br /> NIGHTS: NAME(LAST,FIRST) <br /> PHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED " <br /> NAME <br /> MAILING OR STREET ADORE CARE OF ADDRESS INFORMATION <br /> SS <br /> ✓ boxbiMlyq INOIVOUAL <br /> CITY NAME CORPoggDON 0 PARTNERSHIP 1 LOL AGENCY STATE-AGENCY <br /> STATE O COUNTY-AGENCY Q FEDEML-AGENCY <br /> ZIP CODE PHONE A WITH AREA CODE <br /> 111. TANK OWNER INFORMATION. lli'l BE COMPLETED) <br /> NAME OF OWNER <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADORESS <br /> CITY NAME a box Ii ON 0 INDIVIDUAL C LOCAL-AGENCY 0 STATE AGENCY <br /> STATE ID PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL AGENCY <br /> ZIP CODE PHONE;I WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 i1 questions arise. <br /> TY(TK) HO <br /> V. PETROLE',.1d UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box I 0 I SE-" °� O 2 GUARANTEE <br /> 6 EXEMPTION 0 7 INSURANCE <br /> A SURETYSONO <br /> O 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 PCII T WG WHICH ABOVE ADCRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> I ❑ II ❑ III ❑ <br /> THiS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PAINTED a SIGNATURE) <br /> APPLICANTS MONTHIDAYNEAR <br /> TITLE DATE <br /> M • 5 v�v• p5. 2 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY p JURISDICTION p <br /> mFACILITY X <br /> I <br /> LOCATION CODE -OPT/ONAL CENSUS-TRACT M - 7pAlAL <br /> � � SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION• FORM B�,�UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(5-91) <br /> • /�� FOR60:i3A-5 <br />