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N%41 eyoua A <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A oe <br /> 1 , � •C�(,�011 M.� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ J NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA FACILITY(AM� �A O NAME OF OPERATOR <br /> ADDRESS C NEAREST CROSS STREET PARCEL 0(OPIONAL) <br /> l <br /> 1 <br /> CI NAM STATE ZIRgD , O SITE PHONE s WITH AREA CODE <br /> ��[[ CA {{AA//�� <br /> ✓ Tye CORPORATION INDIVIDUAL (] PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY l�STATE-AGENCY 0 FEDERAL AGENCY <br /> TOINdCATE /` DISTRICTS <br /> TYPE Of BUSINESS ❑ i GAS STATION 2 DISTRIBUTOR [77] q SERVATDION A OF TANKS AT SITE E.P.A. I.D.#(oplimaQ <br /> 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) C EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRS PHONE#WITH AREA CODE DAYS: NA (LAST,FIRST) PHONE <br /> NIGHTS: NAME(LAST,FfRST) PHONE#WITH AREA CODE NIGHTS: NAME( ST,FIRST) PHONE TH AREA CODEE <br /> II. PROPERTY OWNER INF RMATION- MUST BE COMPLETED <br /> NAME i CARE OF ADDFIFSS INFO A <br /> MAILINGOR:TRE RESS `Jjr `� bl � l� IN (DUAL � LOCAL#GENCY l� STATE-AGENCY <br /> 1 JY CORPORATION PM ERSNIP COUNTY-AGENCY Y#GENCY FEDERAL#GENCY <br /> CITU NAM S TE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION- UST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bortw Mcam, E=1 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION l= PARTNERSHIP D COUNTY-AGENCY D FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORA FEE ACCOUNT NUMBER-Call(916)323-9555 if questio s arise. <br /> TY(TK) HQ 4 4 - � <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILI -(MUST BE COMPLETED)—IDENTIFY THE METHOD( USED <br /> ✓ bm b in4kalo = I SELF INSURED [=]2 GUARANTEE 31NSURANCE 4 SURETY BOND <br /> =5 LETTER OF CREDIT =6 EXEMPTION 93 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.O 1 X <br /> III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> EJ <br /> LOCATION DE OPTIONAL CENSUSTRACTD -OPT NAL SUPVISOR-DISTRICTDCODE -O7 NAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE PORMATION ONLY. <br /> FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOflOWJAR6 <br />