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STATE WATER STATE OF CALIFORNIA \� <br /> RESOURCES CONTROL BOAR <br /> UNDERGROUNDSTORAGE TANK PERMIT APPLICATION• FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SrM <br /> MARK ONLY El <br /> 1 NEW PERMIT <br /> ONE ITEM O 3 RENEWAL PERMIT 11 5 CHANGE OF INFORMATION o- 1 <br /> ❑ 2 INTERIM PERMIT 0 d AMENDED PERMIT PERMANENTLY CLOSED SITE <br /> I. FACILIT"1011 t INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> 6 TEMPORARY SITE CLOSURE _ <br /> DBA OR FACIUTY NAME <br /> NAMEOFOPERATOR <br /> ADDRESS <br /> 35 NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME <br /> STATE ZIP CODE <br /> CA SITE PHONE M WITH AREA CODE <br /> 11 BOX TO INDICATE O INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY 0 COUNTY-AGENCY' <br /> DISTRICTS STATE-AGENCY' Q FEDERAL-AGENCY' <br /> 'lonnxdllSTicep�Gc agvxy,mmpWelhA logowng IrmNdsupervisord Ebisbn,section woFNe which np9Nla 9p UST <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR v'IF INDIAN A OF TANKS AT SITE E.P.A- 1.D.0(options/) <br /> Q 3 FARM [� 6 PROCESSOR 0 5 OTHER OHFRESETLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODES: NAME(LAST,FIRST) PHONE•WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE R WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Ioxro ildrale Q PIDMDUAL D LOCAL-AGENCY O STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE MP CODE PHONE M WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxto^6mte E:)INDIVIDUAL LOCAL-AGENCY OSTATE-AGENCY <br /> =CORPORATION = PARTNERSHIP O COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME 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) HO F4-F4--]- <br /> V. <br /> 4 -� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓boxm Yldr�e 171 SELF'WSUREO Q 2 GUARANTEE O 3 INSURANCE I3 A SUPETY 110NO O 5 LETTER OFCREDR O 6 EXEMPTION O T STATE FUND <br /> O B STATE FUhII78 CHIEF FlNMIOAL OFFICER LETTER B STATE FUND ICFATIFICATEOFDEP0.SIT O 10 LOCAL GOVT.MECHANISM M OTHER <br /> Vt. 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: <br /> I.O Ii.[�] III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTYOF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE A MOCORRECT <br /> WIE <br /> TANK OWNERS TITLE <br /> TANKOWNERS NAME(PRINT EDB SIGNATURE) V `�- <br /> LOCAL AGENCY USE ONLY <br /> JURISDICTION tl FACILITY K <br /> COUNTY K m� <br /> mSUPVISOR-DISTRICT CODE •OPTIONAL -y <br /> LLOCA�=ONCODEOIXPWXJ� CENSUSTRACT♦ .OPTIONAL 4 <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 FII'-41S"9M y..-1 THE LOCAL AGENCY IMPLEMENTING THFEr-'O U N.6 ORAGE TANK REGULATIONS <br /> FORM A(6-95) `� �� �✓ <br />