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, I <br /> ty°ua p <br /> STATE OF CAUFORN IA °Oso <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> . . a <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> A'en--[ M <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> / CA 9'S <br /> ZUS <br /> BOX <br /> TOINDICATE CORPORATION Q INDIVIDUAL (]PARTNERSMP IC.AL-AGENCY Q CGUNrYAGENCY STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS (� t gAG STATION 2 DISTRIBUTOR ❑ R SEIRVADIAON #OF TANKS AT SITE E.P.A. I.D.s(goi/maq <br /> `L--£.j''/3 FARM Q 4 PROCESSOR 6 OTHER OR TRUST LANDS / <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRS I PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> lug ,--L-C <br /> NIGHTS: NAME(LAST,FIRST) I PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME /14 1CARE OF ADDRESS INFORMATION <br /> ll.l <br /> MAILING OR STREET ADDRESS r ✓bubl!II INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> =CORPORATION PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 5-a p, �s—/ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS- ✓ box blWkab INDIVIDUAL O LOCAL-AGENCY (]STATE-AGENCY <br /> CORPORATION O PARTNERSHIP COUNrY-AGENCY FEDERAL-AGENCY <br /> CITY NAME - STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD O EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 14T4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box w,kw [=] I SELF INSURED 0 2 GUARANTEE1� 3 1 ANCE 4 SURETY BOND <br /> =5 LETTEROFCREDIT =6 EXEMPTION OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless bo or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1. IL❑ III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> y <br /> LOCATION CODE -OPTIONAL :CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> ca Y >; 9 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> coR!A A(12-DI) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0033A R6 <br /> V �f I <br />