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c <br /> STATE OF CALIFORWA <br /> STATE WATER RESOURCES CONTROL BOARD s R <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A Wag <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O T NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED aaE <br /> ONE REM 0 2 INTERIM PERMIT Q 0 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OPAOR FACILITY NAME NAM I FOPERATOR <br /> IkD <br /> ADDRESS NFAFEST CROSS STREET ARCELI(OPTDNAU <br /> I , <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> C S G CA <br /> I/ Box <br /> T NDCATE O CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY Q COUNTY4kSENCY' O STATE-AGENCY' -Q FEDERAL-AGENCY' <br /> OISTRICTS' <br /> '11 mite,d UST is a public agen mrryIM.the following:name d Superveor 01 division.eedion.W office which operates the UST <br /> TYPE OF BUSINESS T GAS STATION 0 2 DISTRIBUTOR O ✓ IF INDIAN $OF TANKS AT SITE RESERVATION E.P.A I.D.a(apfroTaQ <br /> 7 FARM = 4 PROCESSOR 0 5 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) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME 1 CARE OF ADDRESS INFORMATION <br /> MALINd OR STREETADDRESS ✓ wit mi to C INDIVIDUAL LOCALAGENCY CJ STATE AGENCY <br /> CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERALAGENCY <br /> CITY NAME STATE ZIP OE PHONE#WITH AREA CODE <br /> G4 3a o <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Eos bubbL# Q INDIVIDUAL Q LOCAL AGENCY Q STATE-AGENCY <br /> O CORPORATION Q PARTNERSHIP CI COUNTY AGENCY Q FEDERAL AGENCY <br /> CITY NAME $TATE 21P CODE I PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION LIST <br /> STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-T4- -�T�l�dJL :L.L✓J Z� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—JDENTIFY THE METHODS) USED <br /> ✓ Oor blMkLe I SELF-INSURED O 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> O 5 LETTEROFCREDIT 0 6 EXEMPTION C N OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L= I.= 114= <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 DATE MONTHDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ® � 3I S <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-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 IMFORMATIIIIN 0 Y. <br /> FORM A(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS TVOw {J) <br /> �� %� ��e��om�tT <br />