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• . , C <br /> STATEOFCAUFORNIA .•��.o�"' ` <br /> STATE WATER RESOURCES CONTROL BOARD ; g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA RFACILITY NAME NAME OF OPERATOR 91.j <br /> ADDRESS <br /> NE ESTCROSSSTREET PARCEL 0011)NAL) <br /> CITY NAME <br /> STATE ZIP CODE <br /> SITE HO Ea WITH qEA CODE <br /> f)hICA 6 !o D4 <br /> ✓ BO _ <br /> TO INDICATE yu CORPORATION l� INDIVIDUAL Q PARTNERSHIP EDLOCALAGENCY Q COUNTY-AGENCY' 0 STATE-AGENCY' O FEDEMLAGENCV' <br /> ISTICTS <br /> N Owner of UST Is a public agency,couples the following:nae of Supervisor of division,section. Offic <br /> mwhich <br /> operates the UST <br /> TYPE OF BUSINESS ❑ ) GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN •OF TANKS AT SITE E.P.A. I.D.R(gxiarralJ <br /> 0 3 FARM ❑ 4 PROCESSOR 5 OTHER ❑ RESERVATION <br /> OR TRUST IANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-Optional <br /> DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRS 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 /> MAILING OR STRUTADDRESS ✓ herb INDIVIDUAL <br /> O LOCALAGENCV O STATE AGENCY <br /> CORPORATION O PARTNERSHIP O COUNTY-AGENCY FEDERAL AGENCY <br /> CITY NAME STATIP OOE <br /> CONE ZPONE 4 WITH AREA CODE <br /> ' <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILINGO EETADDRESS ✓ hmbrAbare <br /> 0 INDIVIDUAL Q LOCALAGENCV (]STATE AGENCY <br /> CITU NAME ORPORATION O PARTNERSHIP O COUNTY AGENCY E:1 FEDERAL AGENCY <br /> STATE 21P CODE PHONE N 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 METHOD(S) USED <br /> ✓bes Is Il t SELF-INSURED O 2 GUARANTEE O 3 INSURANCE <br /> O 5 LETTEROFCREDT Q6 EXEMPTION O d SURE YBONG <br /> O 9a OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notilication and billing will be sent to the lank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> 1.❑ II.� III.O <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 a SIGNED) OWNER'S TRLE DATE MONTWDAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# EMP. 3873 JU�RISDIC�TION# FACILITY#0,! d 59 <br /> m F5z lL <br /> LOCATION CODE -OPTIONAL CENSUS TRACTi -OPTIONAL SUPVISOR-DISTRICT CODE -OP7'pNAI. 6 1 <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(SIM) OWNER MUST FILE THIS FORIF THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FpgW3A R7 <br />