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s"zoos a co <br /> STATE OF CALIFORNIA W "; <br /> STATE WATER RESOURCES CONTROL BOARD + <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �, o <br /> H% <br /> �.onn" <br /> COMPLETE THIS FORM FOR EAQWFACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION LD7 PERMANENTLY CLOSED SITE <br /> ONE ITEM L] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 9 <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBA CILITYNAME ` NAME OF OPERATOR <br /> ADDRESS y� � NEAREST CROSS STREET <br /> PARCEL#(OPTIONAL) <br /> U / STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CITY NA CA <br /> TO INDICATE I�CORPORATION Q INDIVIDUAL PARTNERSHIP I� DS RIC SENCY I0 COUNTY-AGENCY [71 STATE-AGENCY 0 FEDERAL-AGENCY <br /> TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION IF INDIAN #OF TAN)(S AT SITE E.P.A. I.D.n(oplionap <br /> 3 FARM ❑ 4 PROCESSOR E_] 5 OTHER OR TRUST LANDS / <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> E. <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxblrld! t# lj INDIVIDUAL 0 LOCAL AGENCY STATE-AGENCY <br /> 0 CORPORATION L�71 PARTNERSHIP O COUNTY-AGENCY Q 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 /> MAILING OR STREET ADDRESS ✓ box bindicab D INDIVIDUAL LOCAL AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ [-4]74 - <br /> V. <br /> 4 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE CO LETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate = I SELF INSURED 0 GUARANTEE [::] 3 INSURANCE 4 SURETY BOND <br /> O 5 LETrER OF CREDIT 6 EXEMPTION E-1 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 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 /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAVNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# C'AjU FACILITY# <br /> LOCATIONCQE -OPTIONAL CENSUS TRACT# -OPTIONA�Ij -x SUPVISOR-DIS ICT CO E -OPTIONAL <br /> t± "Id <br /> THIS FORMA MUST BE ACCOMPANIED BY AT LEAST(21)OR MORE PERMIT PLICATION• FORM B,UZNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) , n CAA* <br /> n - <br /> �q)�/,"1/(/'j/gr ^{/T'Q/yT'AUT([_i <br />