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9 STATE OF CALIFORNIA �• °'� <br /> STATE WATER RESOURCES CONTROL BOARD d dam, e <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ss _ <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O T PERMANENTLY CLOSED.SIT <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I, FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA9P FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL 9(OPTIONAL) <br /> 4 <br /> CITY NAMES STACA ZIP CODE SI;P�H 5r)WITH AREA CODE I k <br /> V'BOX 0 CORPORATION f� INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY OGLYCOUNTY.AGENCY' 0 STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> I owneral UST is a public agency,canpleta the laliDwing name d supen4sord division.sectbn oroKce whin operates the UST <br /> TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTORRESERVATION <br /> O ✓IF INDIAN #OFTANKS AT SITE E.P.A. I.D.#(optional) <br /> 0 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILINd OR STREET ADDRESS ✓ baxlasld'nale 0 INDNIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME, STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> S2riLe, cva. <br /> MAILING OR STREET ADDRESS VQ I v <br /> ✓ bDXta Nei0le OINDIVIDUAL OLOCAL-AGENCY OSTATE-AGENCY <br /> D <br /> CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY D 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 4 4 -EI:1= <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bas Minckah, O 1 SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE 0 4 SURETY BOND 0 5 LETrEROFCRmn =6 EXEMPTIOND T STATE FUND <br /> 0 #STATE RIND&CHIEF FINANCIAL OFFICER LEITER 09STATE FUND&CERTIFICATEOF DEPOSIT 010 LOCAL GOVT.MECHANISM O g9OTHER <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. II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY It pJ <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT C -OPTIONAL <br /> D a �- � <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 /> OWNER MUST FILE THIS FORM&TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROL STORA EpTANK#REGULATIONS <br /> FORM A(6,95) - /I � /� i�71; %ys{ <br />