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N Ct <br /> STATE OF CALIFORNIA ' <br /> STATE WATER RESOURCES CONTROL BOARD .�' a g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM A . <br /> 'N <br /> COMPLETE THIS FORM FOR EACH FAGLITYISRE <br /> MARK ONLY 1 NEW PERMIT O3 RENEWAL PERMIT Q <br /> 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT E 4 AMENDED PERMIT 0 a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> NAME "T <br /> OPERATOR <br /> DPA OR FACILITY NPME n/S`T- <br /> -/ /G PARCELN IOETIDNAU <br /> NEAR TCROSS STREET <br /> ADDRESS i <br /> O //� TE PHONE#W ITH AREA CODE <br /> CITY �NIE / STATE ZIP CODE <br /> 17 5;zr4�FA <br /> ✓ BOX 0 CORPORATION INDIVIDUAL 0 PARTNERSHIP O LOCAL AGENCY COUNTY-AGENCY• O STATE AGENCY• O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS' <br /> If inner of UST is a public agency.complete the following:name of Supervisor of diVisbn,section,or office Which operates the UST <br /> ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.x(aplionap <br /> TYPE OF BUSINESS 0 1 GAS STATION O 2 DISTRIBUTOR 0 RESERVATION I <br /> 3 FARM 0 4 PROCESSOR -�6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) <br /> PHONE x WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> DO I — 2 pHONEx WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST)/ PH x 1T EA O E NIGHTS: NAME(LAST,FIRSn <br /> I1. PROPERTY OWNER INFORMATION- MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME o 1 <br /> / tr A l I/IV Y-17111 /S ✓ box 10 micals <br /> MAILING OR STREET DR S3 0 INDIVIDUAL 0 LOCAL 0 AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY AGENCY 0FEDEFEDEIRAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> TY NAME <br /> i, G�GF�id� T <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> CARE OF A11--SS INFORMATION <br /> tNAMEWNERv aSTREET ADDRESS ✓ boxbindicaN 0 INDIVIDUAL LOCALAGENCV O STATEAGENCV <br /> bCORPORATION 0 PARTNFASHIP 0 COUNTVAGENCY 0 FEOEMLAGENCV <br /> STATE ZIP CODE PHONE#WITH AREA CODE�/,�/� �' 6Zzl/o Ic Z —/C,Z_ <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 /> O 1 SELEINSURED 0 2 GUARANTEE D 3 INSURANCE O 4 SURETY BOND <br /> ✓box blMbate 0 5 LETTER OF CREDIT 0 6 EXEMPTION 0 97 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II.[—] IN. <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&SIGNED) <br /> OWNER'S TITLE DATE MONTWDAYIVEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 7 <br /> 10 <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> T IS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF STIE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS ,-FO1I0W3A-R7 <br /> FORM Al3re31 � � /gyp ✓ �j�D�� <br />