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STATEOFCAUFORNA <br /> STATE WATER RESOURCES CONTROL BOARD ,0 <br /> a UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A .r <br /> �7 COMPLETE THIS FORM FOR EACH FACILRYISITE ` <br /> �4r°nN•• <br /> MARKONLY E] 1 NEW PERMIT ED 3 RENEWAL PERMIT <br /> 6 CHANGE OF SITEINFORMATKNJ O 7 PERMANENTLY CLOSED 917E <br /> ONE REM 0 2 INTERIM PERMIT <br /> Q 4 AMENDED PERMIT � e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DEAD FA ILITYNAME — <br /> MAR r NAME OF OP BATOR <br /> ADDR SS <br /> C��j „� <br /> NEARESTe) S ET PARCELO(0 gNpL) <br /> CITY NAM T J �J�-E.� b <br /> STATE ZIP DE SITE P E i WITH AREA 00 <br /> �/.1 BOXCA _ <br /> TO INDICATE O CORPORATION pp INDNIDUAL 0 PARTNERSHIP � LOCAL-AGENCY <br /> K owner d UST Is a public agenty,oorrOlMe thea fol\IowM n DISTRICTS• ��"tGENCY• I�STATE-AGENCY' 0 FEDEML-AOENCy <br /> 9 erne of Supervisor of XIN6bn,""Hon,W 0100 Which operet S the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTgIBUTOqii <br /> 3 FARM Q d PgOCESSOR 6 OTHEfl <br /> R SERVATION V IF INDIAN i OF TANKS AT SITE E.P.A. I.D.S IoWhne/1 <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> DAYS: NAME(LAST,FIRST) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> C PHONE i WITH AREA CODE <br /> NIGHT . NAME L T.F RST) PHONE i WITH AREA CODE S VK L <br /> O NIGHTS: NAME(LAST,FIRST) <br /> PHONE i WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMaA �' CAPE OF ADDRESS INFORMATION <br /> MAILING OR S EET ADD ES <br /> ES <br /> ✓Dsxbindkets NDIVIDUAL <br /> CITY AM � O CORPOgATION D LOCAL-AGENCY 0 STATE-AGENCY <br /> O PAgTNERSHIP Q COUNTY14GENCY Q FEDERAL-AGENCY <br /> STgTE_ ZIP CODE PHONE s WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) H a <br /> NAME OF OWNEq <br /> � <br /> � e) 11 k1l CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> ✓bsX ID MUS, ED INDIVIDUAL <br /> CITY NAME CORPORATION EDLOCAL-AGENCY0 STATE-AGENCY <br /> STATE PARTNERSHIP �COUNTYAGENCY — FEDERAL-AGENCY <br /> ZIP CODE PHONE S WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(91 r6)322.9669 if questions arise. <br /> TY(TK) HQ <br /> V. PETROLEUM UST FINANCIAL RESPO—NSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bm b indicate 1 SELF-INSU..— I]2 GUARANTEE <br /> 6 LETrEROFCREDT (�8 EILEM..... O S INSUgANCE O 4 SURETYBOND <br /> E:j 90 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be nerd 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: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMYKNOWLEDCE,IST UUEAND CRE TNL <br /> OWNER'S NAME(PRINTED A SIGNED) <br /> OWNTIT <br /> ER'S LE <br /> DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION ar <br /> O�q I�'TI FAIaIL ITY sI--�T'—II <br /> LOCATION CODE -OPT-pNALL CENSUS TRACTS -OP ,V Cp�py�`�PTIOMQ .J <br /> 9lNWISOR-018VQ a CpT1ONAi <br /> THIS FO M M TSE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF I MATION 0 Y. <br /> FORM A rAW) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGU <br /> • -AD - 9s <br />