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- • � sounds <br /> t <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD u dam, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT F—] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT E:] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> MOR FACILITY NAME NAME OF OPERATOR <br /> t <br /> ADDRESSc ^o� © NEARESTCROSS� �� PARCEL M(OPTIONAL) <br /> CITY NAME ��1�(/ STATE ! ZIP CODE�i SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓BOX CORPORATION INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCYSTATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 8 owner of UST is a public agency,complete the following name of supervisor of division,sedan or office which operates the UST <br /> TYPE OF BUSINESS 'GAS STATION 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> IF <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRS PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AR COD 'GONA (LAST,FIRST) PHONE#VA AREA CODE <br /> t>/A - 20 - 2 -G NAAJ ,+srkA4 2a-5 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFR) <br /> NAME 1T S�tM ��A A CARE OF ADDRESSINFORMATION <br /> SdW <br /> MAILING OR STREET ADDRESS �/ ✓ bcx•o r cx—) 'tel INMVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY <br /> 3 1 2 S F R Alfe — =CORPORATION = PARTNERSHIP = COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> �0d�sZ s3so e,4 . �d <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS FORMATION <br /> 7k"t3 Na,✓ M <br /> MAILING OR STREET ADDR S ✓ box to indicate INDIVIDUAL = LOCAL-AGENCY =STATE-AGENCY <br /> SI a 0/14-L l =CORPORATION = PARTNERSHIP =COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAM STAT ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USEDI <br /> v1 box to indicate 0 1 SELF-INSURED O 2 GUARANTEE =3 INSURANCE =4 SURETY BOND =5 LETTER OF CREDIT 0 6 EXEMPTION .K 7 STATE FUND <br /> 8 STATE RIND b CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND 8 CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 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: I.= it.0 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNERS NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATELdMONTHIDAYNEAR <br /> I&AA4,11 JG <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> FTI <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT 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(6-95) OWNER MUST FILE THIS FOR 10H <br /> THE LOCAL AGENCY IMPLEMENTING THE UNDERGRis STORAGE TANK REGULATIONS <br />