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ouwcrs <br /> STATE OF CALIFORNIA AP's cO <br /> f <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A . <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE t <br /> MARK ONLY F7 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSE�p_atjE„ <br /> ONE ITEM Q 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORQCIhLITY NAME l� � � � �� NAME OOSPERATOR <br /> ADD E^S,'•/�i ' � Y � 1� """y���/�"" � j�� I NEAREST C�R'IOSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME � f \ STATE ZIP�iA�F4,,� SITE PHONE#WITH73 AREA CODE <br /> IN-C" ICA clsrL✓.. Eft„ 1 <br /> ✓BOX 0 CORPORATION a INDIVIDUAL Q PARTNERSHIP LOCAL-AGENCY O COUNTY-AGENCY' Q STATE-AGENCYFEDERAL-AGENCY' <br /> TO INDICATE 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 a 2 DISTRIBUTOR " <br /> IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> IF <br /> 3 FARM 0 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH AREA(CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 0IRLAND61 SAMS <br /> NIGHTS: NAME(LAST,FIRST) PHONE#W TH AR CODE GHTS: NAME(LAST,FIRST) PHONE It 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 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It 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 to indicate 0 INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED 2 GUARANTEE =3 INSURANCE [:14 SURETY BOND �5 LETTER OF CREDIT 0 6 EXEMPTION =7 STATE FUND <br /> 8 STATE FUND&C FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT [::] 10 LOCAL GOVT.MECHANISM 0 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: L II.0 IIL <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE-OPTIONAL CENSUSSR T# •OPTIONAL SUPVISOR-DISTRICT CODE •OPTIONAL <br /> 0( sVl <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 /> OWNER MUST FILE THIS FORRV THE LOCAL AGENCY IMPLEMENTING THE UNDERGROJSTORA/G/E TANK REGULATIONS <br /> FORMA(6-95) f--�—�� --�- -- ---_--- <br />