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• • "up C <br /> STATE OF CALIFORNIA <br /> ! STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ,k,pol,,,,. <br /> MARK ONLY f NEW PERMIT 3 RENEWAL PERMIT 5ZS CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE REM a 2 INTERIM PERMIT E::] 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR <br /> _M NAME NAME OF AT R <br /> ADD ss TL`'k^ <br /> 7^ NEARESTC OSS STREET PARCELN(OPTIONAL) <br /> CITY NAME <br /> STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> TO INDICATE D CORPORATION (] INDIVIDUAL (]PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' ATE-AGENCY' = FEDERAL-AGENCY' <br /> If owner of UST is a public agency,complete the following:name of Supervisor of division,section,Doroffl ceswhich <br /> operates the UST <br /> TYPE OF BUSINESS t GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM0 4 PROCESSOR 5 OTHER RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: N ME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 2-02 _y _3ycV <br /> NI HTS: NAM LAST,FIRST) PHONE d WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME <br /> ` �---+ CARE OF ADDRESS INFORMATION <br /> MAILING STREET ADDRESS ✓ Dox bindkate INDIVIDUAL LOCAL-AGENCY <br /> CORPORATION (] PARTNERSHIP = STATE-AGENCY <br /> CITY N E � COUNTV-AGENCY � FEDERAL-AGENCY <br /> STAT_ Lh 'Y ZIP CODE ' PHONE#WITH AREA CODE <br /> Z,0 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate <br /> (] INDIVIDUAL (] LOCAL-AGENCY = STATE-AGENCY <br /> CITY NAME O CORPORATION = PARTNERSHIP = COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> Vii Zi 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 44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box io indicate 0 1 SELF-INSURED =2 GUARANTEE 0 3 INSURANCE (]4 SURETY BOND <br /> 5 LETTEROFCREDIT =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: I.0 11. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE <br /> DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> . 4 -,-10 jaq3P) <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OP77ONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APP - FORM B,UNLESS THIS IS A CHANGE OF SM INFORMATION ONLY. <br /> FORMA(3/93) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 0 0 <br /> FOR0033AA7 <br />