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_fie <br /> -.- STATEOFCAUFORMA ` — <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ,s <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT CHANGE OF INFORMATION O T PERMANENTLY CLOSEtmu <br /> ONE REM 2 INTERIM PERMIT 6 AMENDED P til & TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR CILITY AME (?,!:), NAMEOFOPERATOR <br /> ADDRESS / • NEAREST CROSS STRE PARCEL e(OPTIONAL) <br /> CITY NAM t j STATE OtqODE JSITE PH ON WITH AREA CODE / <br /> Ci CAI/ Box <br /> TO INDICATE O CORPORATION 0 INDIVIDUAL =PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY' STATE-AGENCY' 0 FEMRALAGENCY' <br /> DISTRICTS' <br /> N owner ol UST Is a public agency,conplele the following:name of Supervisor of d"lon,section,or ogica whkh operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR 0 ./ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a(opfavwl) <br /> RESERVATION <br /> O 3 FARM A PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(L_AST,FIRST) PHONE A ITH AREA•�CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> JC ; of <br /> NIGHTS: NAME(LAST, IRST) PHONE a WITH A A CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> IIt 1 a0 <br /> If. PROPERTY OWNER INFO MATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boa 0inkare INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION PARTNERSHIP CCUMY.AGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(M TBE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa biMkale INDIVIDUAL O LOCAL AGENCY 0 STATE AGENCY <br /> CORPORATION O PARTNERSHIP (]COUNTYAGENCY FEDERALAGENCY' <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE CCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MU BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boabiMkate (] I SELF INSURED (]2 GUARANTEE O 3 INSURANCE O A SURETYBONO <br /> 5 LETTEROFCREDT 8 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notifies' n and billing will be sent to the tank owner unless box I or It is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= it.❑ 111.❑ <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) OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY AT JURISDICTION a FACILITY• <br /> LOCATION TIONAL CENSUS TRA a -OPTIONAL SUPVISOR-DISTRICT -OPTIONAL <br /> THIS F M MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM S,UNLESS THIS IS A CHANGE OF SITE INFoRMAmolm ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> RMA(3r93) G �r � �EG,-5 <br /> i -3 <br />