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• Af <br /> STATE OF CALIFORMA p � <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> ❑ 1 NEW PERMIT F-1 /'�3 RENEWAL PERMIT _ CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE <br /> MARK ONLY ❑!T S TEMPORARY SITE CLOSURE <br /> ONE REM F-12 INTERIM PERMIT E::] 4 AMENDED PERMIT <br /> I, FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED)NAME OF OPERATOR <br /> DBA OR FACILITY NAME I <br /> A save L <br /> S NEAREST CROSS STREET PMCELi(OPfI <br /> ADDRESS ,& A,�! ' A _ _ ` k5, 1(JIT AR <br /> Jv (/�w•T STA ZIP ODE TE PHO #WITHAREACCIDE <br /> CITY NAME CA <br /> �x LOCAL-AGENCY Q COUNTY-AGENCY' O STATE-AGENCY' <br /> O FEDERAL-AGEWY' <br /> TOINDICATE CORPORATION INDIVIDUAL PARTNERSHIP DISTRICTS' <br /> •I Dant of UST Is a public agency,ocniplete the following:name of Supemieor of division,section.or office whlehWer operates <br /> the <br /> N OF TANKS AT SITE E.P.A. I.D.#(aPtionep <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> EMERGENCY IbNTACT PERSON (PRIMARY) PHONE#WITH AREA CODE <br /> DAYS: NAME(LAS ,FIRST) PHONE#WITH AREA CODE- DAYS: NAME(LAST,FIRST) <br /> a'Am a PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) y i PHONE i WITH MhA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME d <br /> ( ,/ 6orniMkab Q INDIVIDUAL O LOCALAGENCY Q STATEAOENCY <br /> MAILING OR STREET ADDRESS <br /> CORPORATION � PARTNERSHIP a COUNfVAGENCY 0 FEDERAL-AGEI&Y 1 <br /> CITY N <br /> 35 GtJ ZIP CODE <br /> s PHONE#WITH AREA CODE <br /> Fye D ST <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAMEOFOWNER — !•` cAie , <br /> rbinEi'M 0 INDIVIDUAL El LOCALAGENCY IJ STATE-AGENCY <br /> MAILING OR STREET ADD SS `D <br /> CORPORATION [D PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> P. D s S X ZIP CODE PHON #WITH AREA CODE <br /> SRA <br /> CITY NAME !-. Cr <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 U questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOO(S) USED <br /> I SELF-INSURED ED 2 GUARANTEE [_1 3 INSURANCE L_j 4 SURELY BOND <br /> ./ botbWkdN CD EmMPTION 99 OTHER <br /> 0 5 LETTER OF CREDIT <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 /> FOR LEGAL NOTIFICATIONS BILLING: <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED <br /> ❑ u.❑ ul. <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) <br /> OWNER'STRLE DATE MONTH/DAYNFAR <br /> LOCAL AGENCY USE ONLY e b '� 7 <br /> COUNTY# JURISDICTION# FACILITY# <br /> CODE -OP7N)NAL CENSUS TRACTi •OPTIONAL <br /> SUPVISOR-DISTRICT CODE -OPTIONAL <br /> LOCATON <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 STORAGGE�TANK REGULATIONS , <br /> FORM A(393) <br />