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STATE OFCALIFORWA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A effi <br /> P O <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> O�l,I0a4•� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T <br /> ONE REM 2 INTERIM PERMIT PERMANENTLY CLOSED SITE <br /> ❑ < AMENDED PERMIT ❑ g TEMPORARY SITE CLOSURE <br /> L FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DPA OR FACILITY NAME <br /> L NAME OF OPERATOR <br /> ADDRESS <br /> NEAREST CROSS STgEET PAgCFl s(OPfONAU <br /> 1, r✓L y�� <br /> CITU NAME_ STATE ZIP CODE <br /> SITE PHONE s WITH AREA CODE <br /> ✓ Box CA 7 <br /> TO INDICATE 1:7)CORPORATION 0 INDIVIDUAL ED PARTNERSHIP LOCAL-AGENCY [-3 <br /> COUNrY-AGNDISRIOT3 Y' D STATE-AGENCY, 0 FEDERAL#GENCY' <br /> N ams,of UST IsaW blit agency,conpAe the following:nartw of Supervisor of division.section,or office <br /> which operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN s OF TANKS AT SITE E.P.A. I.D.g(nprbrwf) <br /> ❑ 3 FARM ❑ A PROCESSOR 5 OTHER ❑ RESERVATION <br /> ❑ OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONELWITHREA CODENIGHTS: NAME(LAST,FIRST) PHONE S WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONEREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESSl ✓box bbdkaN INDIVIOVAL DLOCAL-AGENCY D STATE-AGENCY <br /> • -D• / O I]CORPORATION E71 PARTNERSHIP D COUNTY AGENCY D FEDERAL#GENCY <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA COD <br /> aG 0 9 Zol al.68- <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER D � � CARE OF ADDRESS INFORMATION <br /> -4r �T A4L>1 OWr <br /> MAILING OR TI E] <br /> STREET ADDRESS ✓box Windom INDIVIDUAL l� LOCAL-AGENCY I1 STATE-AGENCY <br /> • O <br /> 167 a D CORPORATION D PARTNERSHIP COUKIYAGENCy O FEDERAL-AGENCY <br /> CITY NAMEST(/A ZIP CODE PHONE�(WITH AFLEA CODE <br /> Z♦9 N60G 66 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-F4--]- <br /> V. <br /> 4- -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bYlGegs [__1 1 SELF-INSURED Q 2 GUARANTEE D 3 INSURANCE (]A SURETY BOND <br /> E-�]5 LETTEROFCREOIT g EXEMPTION 0 w 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 /> C14ECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.0 II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED A SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY It JURISDICTION As FACILITY# N� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR DISTRICT CODE -OPTIONAL <br /> r 3, D -3 <br /> OR MUST BE ACCOMPAN <br /> THIS FIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE ITFORMATION dNLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A 1 (93) FORMM-117 <br />