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0 <br />e <br />STATE OF CALIFORNIA APP cO <br />STATE WATER RESOURCES CONTROL BOARD a <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />• CSI IFOR N.� <br />COMPLETE THIS FORM FOR EACH FACILITYISITE <br />MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT E:] 5 CHANGE OF INFORMATION 7 PERMANENTLY C OSE <br />ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA Cr7ACILITY <br />/N%AMEE <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />PHONE A WITH AREA CODF <br />NAME OF OPERATOR <br />PHONE # WITH AREA CODE <br />ADDS15S <br />,/�V/- a <br />PHONE # WITH AREA CODE <br />LOCATION CO E -OPTIONAL <br />NEAREST CROSS STREET <br />CENSUS TTT # -OPTIONAL <br />PARCEL#(OPTIONAL) <br />CI VE <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />CA <br />✓ BOX <br />TO INDICATE <br />O CORPORATION INDIVIDUAL PARTNERSHIP <br />0 LOCAL -AGENCY COUNTY -AGENCY <br />0 STATE -AGENCY FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS <br />1 GAS STATION <br />2 DISTRIBUTOR <br />/ IF INDIAN <br />OF TANKS AT SITE <br />E. P. A. 1. D. # (optional) <br />RESERVATION <br />III <br />3 FARM <br />0 4 PROCESSOR 0 <br />5 OTHEROR <br />TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) . optional <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />PHONE A WITH AREA CODF <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE A WITH AREA CODE <br />If. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box b indicate INDIVIDUAL 0 LOCAL -AGENCY 0 STATE -AGENCY <br />Q CORPORATION 0 PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to indicate INDIVIDUAL OLOCAL-AGENCY OSTATE-AGENCY <br />CORPORATION PARTNERSHIP 0 COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />TY (TK) HQ 4 4- 010101 3 0 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THEM HOD(S) USED <br />✓ box to indicate 0 1 SELF-INSURED 0 2 GUARANTEE 0OOFINSURANCE 4 SURETY BOND <br />5 LETTER OF CREDIT 6 EXEMPTION 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: 1.0 II. 0 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 MONTHIDAYNEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # <br />e2! <br />JURISDICTION # <br />FACILITY # <br />C3� <br />gF�-co 3 0 <br />� <br />� S ZlZlo`Rv <br />LOCATION CO E -OPTIONAL <br />CENSUS TTT # -OPTIONAL <br />SUPVgs,R - 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 />FORM A (5-91) FOR0033A-5 <br />