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...r Baa"' e <br /> STATE OF CAUIFORNA e� <br /> STATE WATER RESOURCES CONTROL BOARD „g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A , . <br /> COMPLETE THIS FORM FOR EAC ACIL.ITY/SrTE <br /> MARK ONLY Q 1 NEW PERMIT E::] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY D SITE <br /> ONE REM Q 2 INTERIM PERMIT Q d AMENDED PERMIT 5 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA FACILITYN E ' ^ NAME OF OPERATOR <br /> �J <br /> ADDRESS NEAREST CROSS STREET PARCEL A(OPTONAD <br /> CITY NAME STATE ZIP CODE SITE PHONE*WITH AREA CODE <br /> CA CA <br /> To Ni NIDI ACiE RPOMTION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTKAGENC <br /> DISTRICTS' Y• Q BTATE.AGENCY• Q FEDERAL-AGENCY. <br /> •n owner d UST leap ime TNa fodm q:name d Supervc of dl 4m o ,PeCTion.w officeamich oparaIaa U.UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN *OF TANKS AT SITE RESERVATION E.P.A. I.D.A(apHwW) <br /> 0 3 FARM Q A PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-apttonal <br /> DAYS: NAME(LAST.FIRST) rPHONEe WITH AREA CODE DAYS: NAME(LAST.FIRST(S PHONE WITH AREA CODE <br /> To - ;}� _ 77 <br /> NIGHTS: NAME(LAST,FIRST) PHO WITH AREA CODE NIGHTS: NAME(LAST.FIRST) —PHONE*WITH AREA CODE <br /> O <br /> It. PROPER OWNER IN RMATION• MUST BE COMPLETED <br /> NAMECARE OF ADDRESS INFORMATION <br /> TNe <br /> MAILING OR STREET ADDRESS ✓ IaAOIIIEI'aM Q INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY <br /> 2 Q CORPORATION Q PARTNERSHIP Q COUNTYAGENLY Q FEDERAL AGENCY <br /> CITY NAME TA 21P HO WITH AREA CODE <br /> 4 u _ o <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF NEP CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa NYNraY Q NINVIWAL Q LOCAL AGENCY Q sATE AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q GOUNTY-AGENCY Q FEDERALAGENCY <br /> CITY NAME STATE MP CODE PHONE*WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ F4-T47- Z(o <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓�bb'r� Q I SELF INSURED Q 2 GUARANTEE Q 3 INSURANCE Q A SURETY BOND <br /> 0 5 LETTEROFCRECIT Q B ExEMPTION Q 90 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L= ILE] 111.D <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY ANOWLEDGE.IS TRUE AND CORRECT <br /> OWNE R'S NAME(PRINTED B S IGNED) OWNER'S TDLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION• FACILITY• <br /> ® aE�; Ill 154 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT* -OP77ONAL 9UNISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM Br UNLESS THIS IS A CHANGE OF SITE WC)RMATKIN bNLY. <br /> FORM A CV113) OWNER MUST FILE THIS FORM WI0W <br /> I0 THE LOCAL AGENCY IMPLEMENnNG THE UNDERGROUNIJSTORAGE TANK REGULATIONS FOFWM3A4T7 <br />