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• �0oOaces <br /> STATE OF CALIFORNIA P �" <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A a��' e <br /> V C�c iron N� <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY (7 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION n 7 PE ANE SITE <br /> ONE ITEM , 2 INTERIM PERMIT 4 AMENDED PERMIT U 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMP ETED) <br /> DBA OR FACILITY NAMEE OF OPERATOR <br /> __ D t <br /> ADDRESS r Zp NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME v STATE ZIP CgQE _ I SITE PHONE#WITH AREA CODE <br /> l CA <br /> To INDICATE O CORPORATION F__1 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY COUNTY-A NCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS a I GAS STATION 2 DISTRIBUTOR / IF INDIAN # TANKS AT SIT I E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGEN Y CONTACT RSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIR <br /> PHONE#WITH AREA CODE _ <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 5CARE OF ADDRESS INFORMATION <br /> s _ <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> Ls GD—f/� E::]CORPORATION E�:] PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME ST2 ZIP CODES PHONE#WITH AREA CODE <br /> 1170 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) 9 <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> sem,e, CA7 <br /> MAILING OR STREET ADDRESS• ✓ box to indicate INDIVIDUAL <br /> 0 LOCAL-AGENCY [ -] STATE-AGENCY <br /> 0 CORPORATION 0 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)323-9555 if questions arise. <br /> TY(TK) HQ F4414�- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate t SELF-INSURED 0 2 GUARANTEE (] 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT 0 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 AND BILLING: <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 8 SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> J <br /> LOCAL AGENCY USE ONLY l�r1 <br /> COUNTY# �'r-A go JURISDICTION# FACILITY# <br /> LOCATION CODE OPTIONAL 1 CENSUIT# -�TIONAL SUPVISQR-DIST ICT CODE -OPTIONAL <br /> Cl I -I If2s <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 /> FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> �� LL- 0 j � FOR0033A-R6 <br />