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STATE OF CALIFORNIA °•, <br /> STATE WATER RESOURCES CONTROL BOARD <br /> /UNDERGROUND STORAGE TANK PERMIT APPLI TION- FORM A ae <br /> �•OXM• <br /> COMPLETE THIS FORM FOR EAC CILrTY/SITE <br /> MARK ONLY O I NEW PERMIT O 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION 0 ] PERMANENTLY CLOSE <br /> ONE ITEMF 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 9 9 <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR / <br /> ADDRESS NEAREST CROSS STRWET PARGELA(0 <br /> � �1� �• C`tGi�ei W S�ttnis�urts � 3y (o,/ <br /> CITY NAME STATE ZIP CODE SITE PHONE N WITH AREA CODE <br /> S/V CA 9savto00 _Y6 Y-d� C2 <br /> v Box <br /> TOINDICATE D COB ON INDIVIDUAL 0 PARTNERSHIP Q L CA�TGENCY 0 OOUF[Y-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DSTTYPE OF BUSINESS EV 1 GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.•(optimal) <br /> RESERVATION <br /> 3 FARM ] 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NA E(LAST,FIRST) PHONE 0 WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> a 5A; - s� -V4 PHONE a WITH AREA r=9 <br /> NIGHTS: NAME(LAST.FIRSn PHO ESWITHAREACODE NIGHTS: NAME(L IT IRST) <br /> _G%a 7e PHONE 9 WITH AREA GOOF <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> J6egai- mce o/ <br /> MAILING OR STREET ADDRESS `� box bx:Ne INDIVIDUAL D LOCALAGENCY STATEAGENCY <br /> © U P/, f' Q CORPORATION = PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME / STATE ZIP CODE PHONE A WITH AREA CODE <br /> /' ' <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> s4 S <br /> MAILING OR STREET ADDRESS ✓box bintlbab 0INDIVIDUAL OLOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP �COUNTY-AGENCY D FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. <br /> TY(TK) HQ 4 4 <br /> V, PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD ED <br /> ✓ box binEkW Q I SELF-INSURED �2 GUARANTEE 0 3 ANCE 0 4 SURETY BOND <br /> (]5 LETTER OF CREDT a EXEMPTION OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> 1. II.O III.Q <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) <br /> APPLICANTSTITLE DATE MONTWDAWYEAR <br /> LOCAL AGENCY USE ONLY t� <br /> LOCATION CODE -OcPTIOuNAL # CENSUS TRAJURISDICTION# � <br /> FACILITY <br /> 3 <br /> -4:V- N <br /> 3c/ CTSUVIOR-DISTR DE -OPTIONAL <br /> .CT� J b <br /> R <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(t)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATIONFC3Ad <br /> ON ON <br /> FORM A(5-91) <br />