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1 <br /> a <br /> bovq <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD s 4a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A os <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 40poro." <br /> MARK ONLY O f NEW PERMIT E] 3 RENEWAL PERMIT >e 5 CHANGE OF INFORMATION a 7 PERMANENTLY C SITE <br /> ONE REM F_� 2 INTERIM PERMIT Q 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA O._ NAMEOFOPERATOR <br /> ADDRESS -a-- <br /> NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE -4SITE PHONE#WITH AREA CODE <br /> _ r— Y:Ac–y CA e-- V <br /> TO INDICABox <br /> CORPORATION 0 INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY' 0 STATE-AGENCY' FEDERAL-AGENCY' <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 t.� t GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST <br /> TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRSPHONE#WITH AREA CODE DAYS: NAM -�}E(LAST,FIRST) PHONE#WITH AREA CODE <br /> tA1� ` ,91 7 e 1 3- 1 L�)q L-I�TFZ1a.i auk - 1l - , <br /> NIGHTS: NipsimiSSn PHONE 8 WITH AREA CODE lNIGHTS: NAME(LAST,FIRST) PHONES WITH AREA CODE <br /> -3 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CAREDDRESS INFORMATIQN <br /> ) <br /> $ REET ADDRESS ..e box lo Indicate n INDIVIDUAL 0 LOG STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP (]COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> STATE ZIP CODE <br /> REA CODE <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CAJIE OF ADDRESS INFO TIO <br /> M TREET ADDRESS - (]STATE-AGENCY <br /> PORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> .BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4T4--]- (� �{ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED <br /> box bindices >�I SELF-INSURED CI 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BONG <br /> 0 5 LETTER OF CREDIT 0 6 EXEMPTION 0 go 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: I.[:] 11.a III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> N NAM RINTED I 'E ) ( /I ✓1'n� }/�I OWNER'S TITLE E� I � ( DATE M TWDAYNEAR <br /> LOCAL AGENCY US NLY <br /> COUNTY# JURRISDDII�CTION# FACILITY <br /> ® ✓/ <br /> LOCATION CODE -OPTIONAL i CENSUS TRACT# -OPTIONAL SUPVISOR-DI-STRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. / <br /> FORMA(3(93) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATM \� <br /> • FOR0033A <br />