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a <br /> AL <br /> ."e,. <br /> ,� s i. r -. r •. ads .. '`'�, E. s, <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD F—MAN� a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA <br /> s COMPLETE THIS FORM FOR EACH FACILITY/SITE c-,won 3 <br /> MARK ONLY 1 NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE rTEM F-1 2 INTERIM PERMIT 71 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> SRA OR FACILITY NAME NAME OF OPERATOR <br /> WZ- <br /> ADDRESS NEAREST CROSS STREET PARCEL N(OPTIONAL) <br /> CITY NAME STATEZIP CODE SITE PHq NE WITH AREA CODE *J <br /> All A CA <br /> ✓Box <br /> TO INDICATE F--1 CORPORATION INDIVIDUAL Q PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCYE�:] STATE-AGENCY' Q FEDERAL-AGENCY' v <br /> DISTRICTS' <br /> If owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR <br /> 5 OTHER ✓ IF INDIAN #OF TANKS'AT SITE E.P.A. I.D.#(opfional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR OR TRUST LANDS <br /> F �4 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional F <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE WITH AREA CODE f' <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE pUGHTS: NAMEOMT,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP [] COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME ZIP CODS 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 y,:/yr ® ✓ box bindcate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP (]COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)32269 if questions arise. <br /> TY(TK) HQ M44, <br /> r <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED }' <br /> 1SELF-INSURED (�2 GUARANTEE [] 3 INSURANCE 4 SURETY BOND <br /> ✓ box b indicate h; <br /> D 5 LETTER OF COEDIT Q 6 EXEMPTION 99 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 ANDSILLING: 1.0 ILI� III. <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 MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# k JURISDICTION# FACILITY# <br /> * LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL ---[SUPVISOR-DISTRICT CODE -OPTIONAL <br /> LOCATION CODE -OPTIONAL —7� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMITAPPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOC AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIM b <br /> FORM A Tom. r'";� • � —"v� ,k.,�.."�*�Y .'� �` �s.=� `- ���` � FOR0009A-R7 <br />