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• � Pe6ouA ps c <br /> STATE OF CALIFORNIA <br /> a <br /> STATE WATER RESOURCES CONTROL BOARD w , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A 40 <br /> • C��If OM N.� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ® r <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> o d or_rl- <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAIVE STATE ZIP CODE S TE PHONE#WITH AREA CODE <br /> S-fD G Ca <br /> ✓ BOX <br /> TO INDICATE CORPORATION (]INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> [7P—EOF BUSINESS EV1 GAS STATION 2 DISTRIBUTOR / IF INDIAN r7KS AT SITE I E.P.A. I.D.#(optional) <br /> RESERVATION <br /> a 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PEXSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) "'PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHO #WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE WITH A EA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION - <br /> MAILING OR STREET ADDRESS ✓ box to indicate E::] INDIVIDUAL E::] LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE 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 N <br /> Io indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> RPORATION 0 PARTNERSHIP 0 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 16)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 -1010101 <br /> V. PETROLEUM UST FINANCIA RESPONSIBILITY-(MUST BE COMPLETED)—IDE TIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 2 GUARANTEE E=] 3 INSURANCE Q 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION 0 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to a 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.= II.E::] III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY �o c;_ <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> o - O 3 a a-- <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(5-91) �_ � �y�n/ �h�p FOR0033A•5 <br /> I <br />