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a.i STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD e� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOO EACH ACIUfYISITE <br /> NAR�ONLYf7 I NEW PERMIT 4 RENEWAL PERMIT 5 CHANGE OF INFORMATION � 7 PERMANENTLYON2 INTERIM PERMIT Q a AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FAC LITYISITE INFORMATION 3 ADDRES -(MUST BE COMPLETED) <br /> DSA AGILITYNAME NAME Of QP OR �� <br /> NEARESTCRO S EET PIACELaIOPTIOKW <br /> CI NAME STATE /CA ZIP f57e / SITE PHONEi AR CODE <br /> TOI/ BOX INDICATE CORPORATION IQ IMIA UAL Q PARTNESHIP Q �S' Q CWNfYJ(iENC4' Q SPATE-AGENCY* Q FEDERA4AGENCY- <br /> II caner d UST Is a PoOPe agency.oonOm U,e 1010wing:Panel d So XNnI m at'Nil Icn,eennn.w gKlo*ncN c"am"me UST <br /> TYPE OF BUSINESS Q I GAS STATION Q^ 2 DISTRIBUTOR Q R,/ <br /> IF INDIAN <br /> a OFT AT SITE F <br /> 'J P.A I.D.a(gPIJUPa11 <br /> 0 7 FARM 4 PROCESSOR Q 5 OTHER OR ESERVA ON <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY).optional <br /> DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> ?HONE a WITH Af1EA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> _ I CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING OR STREET ADDRESS JOU DYnbM Q INDIVIDUAL Q LOCA IGGENCY Q STATE AGENCY <br /> Q CORPORATION CJ PARTNERSHIP Q COUKrYAGENC/ Q FEDERAL-AGENCY <br /> 14� IP <br /> STATE IJP CODE PHONE a WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> MALI 4G OR STREET ADDRESS J bw n,n c� Q INDIVUUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FED PP %GSWY <br /> CITY NAME STATE I ZIP CODE PHONE a WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 it questions arise. <br /> TY(TK) HQ F4747- <br /> V. <br /> 4V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED IsuREr�xo <br /> Q I SELF-INSURED Q 2 GUARANTEE Q 5 INSURANCE Q <br /> ✓ boaaa6rala =5 LETTEP OFCREIXT Q 6 EYEWTION Q So OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing Will be sent to the tank owner unilmii,6ox I or II is checked. <br /> CHECK ONE SOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> I. II.= III.= <br /> THIS FORM HAS 8EEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED 8 SIGINED) <br /> OWNER'S TITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JURI�% ^ ry F <br /> ACILITY`s <br /> LOCATION CODE -OPTIO CENSUS TIUCT. suPVLSoa-olsTTiIc/r �.L_L1J <br /> THIS FORM MUST BE/ MPANED BY AT LEAST(1)OR MORE PERMIT APPLICATION. FORM B,UNLESS THE ISA CI&AGE OF SITE INFORYATWN ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TAN(REGULAJH , FaRomaan <br /> FORM A(194) r / <br />