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.�5 <br /> STATE OF CALIFORNIA '.a cos <br /> STATE WATER RESOURCES CONTROL BOARD 3� g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> f OA <br /> MARK ONLY Cl NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE211 <br /> ONE ITEM a 2 INTERIM PERMIT 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> CL <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 1 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> S CA <br /> W, BOX CORPORATION D INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY Q COUNTY-AGENCY' STATE-AGENCY' FEDERAL-AGENCY' <br /> TO INDICATE. DISTRICTS <br /> If owner of UST is a public agency,complete the Iofbwng: name of supervisor of division,SW*n or office whist operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓IF INDIAN I#OFTANK8 AT SITE E.P.A. L D.#(optionef) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR 5 OTHER DR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRS - lJ,�PPHONE#WITH AREA CODE (� DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> — Dl V <br /> NIGHTS: NAME(LAST, IRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> AME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREM ADDRESS ✓ box to nclicate <br /> i 0 INDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP [] COUNTY-AGENCY [= FcCERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NA E OF OWNER CARE ADDRESS INFORMATION <br /> MAILING OR STREET DDRESS ✓ box to indicate INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> . \ ORPORATION © PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME S ATE ZIP CODE PHONE N WITH AREA CODE <br /> sy <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓to.to indicate E�] 1 SELF-INSURED © 2 GUARANTEE 0 3 INSURANCE Q 4 SURETY BOND 0 5 LETTER OF CREDIT = 6 EXEMPTION 1__)7 STATE RIND <br /> O 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND s CERTIFICATE OF DEPOSIT I] 10 LOCAL GOVT.MECHANISM ED 99 OTHER <br /> V1. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> SS <br /> KHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L L] fl.0 111.. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P ThE HEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> T fdfY N,ME(PIR NTED ,NATUR A R, LE 0* 40DATE MONTWI? Y AR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE ..OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> Z <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE IN RMATI N bkY. <br /> FORMA(6-35) 0VINER MUST FILE THIS FO or <br /> THE LOCAL AGENCY IMPLEMENTING THE UNDERGR TORAGE TANK REGULATIONS <br />