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STATE OF CALIFORNIA ��^-•~•-- c�'. <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE v- <br /> =MARK �' NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE <br /> 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION_&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS " NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> G `I.-I t '/ c <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> -cammo a CA <br /> ✓BOX CORPORATION C:3 AI r4of C:3 PARTNERSHIP C:3 LOCAL-AGENCY COUNTY-AGENCY' STATE•AGENCY• F `z�AL•AGENCY <br /> TO INDICATE DISTRICTS <br /> '#owner d UST is a pulk apuy,-MI-te the f-k"i+¢tarns d supervisor d t4'on,sedgy or otraa whidt WerMo the UST <br /> IF INDIAN 1TYPE OF BUSINESS 0 t GAS STATION C:] 2 DISTRIBUTOR RESERVATION #OF TANKS AT SITE E P.A i.D.#(optionaq <br /> Q 3 FARM Q A PROCESSOR Cn5 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,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHON #WITH EA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 9�1 FJut NO cw <br /> LING OR STREET ADDRESS ✓ box to°�cate ®INDIVIDUAL ®LOCAL-AGENCY C3 STATE-AGENCY <br /> MAI <br /> MAI ® S (a'GORPORATION (]PARTNERSHIP ®COUNTY-AGENCY ® F�E'+AL-AGENCY <br /> 'IDLl <br /> CITY NAME STATE ZIP CODE ONE#WITH AREA COO_ <br /> !Sqld 1«- a58 (�I. /-X7.4 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> P, <br /> MAILING OR STREET ADDRESS ✓ box to Fdi ale INDIVIDUAL r_1LOCAL•AGENCY r7 STATE-AGENCY <br /> •®. 3 CORPORATION a PARTNERSHIP [�COUNTY-AGENCY []Fe''').ERAL•AGENCY <br /> CITY NAME STATE ZIP CODE P ONE#WITH AREA CODE <br /> -75--7— S <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-T47- - 3 t 1 -1 1 1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> Fb-,at?.. 1 SELF.INSURED 0 2 GUARANTEE 0 3 WWR44E M 4 SURETY BOND O 5 LETTER OF CREDIT C7l 6 EXEMPTION C_1 7 STATE FUND <br /> C D 6 STATE FUND&CHIEF FINANCIAL OFFICER LEITER (__19 STATE RIND a CERTIFICATE OF DEPOSIT [__310 LOCAL GOVT.MECHANISM E D 99 OTHER=_— <br /> __—--- <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: 1. II.❑ 111• <br /> THIS FORM HAS BEEN COMPLETED U R PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> T K OWNER'S NAME(PRINTED 3 SIGNATURE) S TITLE DATE ;WDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACIUTY# <br /> m � <br /> LOCATION CODE-OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> J <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 WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />