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• • � PtsaVn«S C <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A s <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE t� <br /> MARK ONLY �1 NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED,SITE <br /> ONE ITEM E] 2 INTERIM PERMIT 0 4 AMENDED PERMIT Ej 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR L <br /> ADDRESS! NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> y. <br /> CITY NAME STATE ZIP C9QE SITE PHONE#WITH AREA CODE <br /> C CA -71 <br /> ✓BOX CORPORATION (] INDIVIDUAL = PARTNERSHIP D LOCAL-AGENCY COUNTY-AGENCYSTATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> #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 BUSINESS1 GAS STATION 0 2 DISTRIBUTOR v'IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION v) <br /> 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> f� DAYS: NAME(LAST,FIRST) D ONE#WITH AREA C DE DAYS: AME(LAST,FIRST) a PHON #WITH AREEA_CODE <br /> lyJ2 OQ � �P <br /> NI TS: NAME(LAST,FI ST)) PHO #WITH, CODE NIGHTS: NAME(LAST,FIRST) PHO #WITH AREA CODE <br /> AL Vai, <br /> 11. PROPERTY 0 NER INFORMATION-(MUST BE COMPLETED) <br /> NAME / CARE OF ADDRESS INFORMATION <br /> U4 C <br /> MAILING OR STREET ADDRES _ ✓ box to indicate Q INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> Q CORPORATION 0 PARTNERSHIP D COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STAT ZIP CODE P ONE#WITH AREA CODE <br /> } -iso <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 LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION Q PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE 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 M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE F_-1 4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION 0 7 STATE FUND <br /> Q B STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&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. III. <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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY 3 14 1 <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DIST T COD •OPT ONAL <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 FORM#THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU STORAGE TANK REGULATIONS <br /> FORMA(6-95) <br /> 4 <br />