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a <br />STATEOFCAUFORMA <br />STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EAC CILRY/SITE <br />MARK ONLY I7 I NEW PERMIT O 3 RENEWAL PERMIT lid 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSE <br />ONE REM � 2 INTERIM PERMIT Q d AMENDED PERMIT Q 5 TEMPORARY SITE CLOSURE "�� <br />I. FACILRYISITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DB O ACILITYN <br />NAMED OP TOR <br />DAYS: NAME (LAST. FIRST) <br />PHONE # WITH AREA CODE <br />A S <br />NEAREVI RO�TRE <br />PARCELO(OPTIONAU <br />PHONE N WITH AREA CODE <br />NAME <br />C NAME/ <br />STATErrGG''//''77//'' ZIPC7 D <br />2 <br />SI PHONE#WITH AREA CODE <br />CABOX <br />, <br />TO INDICATE E:I CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL -AGENCY O COUNTY -AGENCY' O BTATE-AGENCY' = FEDERALADENCY' <br />DISTRICTS' <br />' N owner ol UST Is a public agency, aonpMle the following: name of Supervisor of divblon, section, of office Which operates the UST <br />TYPE OF BUSINESS O I GAS STATKIN Q 2 DISTRIBUTORO <br />IF INDIIAN <br />OF TANKS AT SITE <br />E. P. A I. D. # (epoonw) <br />Q 3 FARM d PROCESSOR 5 OTHER <br />RE9 # <br />OR TRUST LANDS <br />?/ <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - rational <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LAST. FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST. FIRST) <br />PHONE i WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE N WITH AREA CODE <br />It. PROPERTY OWNER INFORMATION - (MUST BE COMPLETEn1 <br />NAME - <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ Cos b CdM ED INDIVIDUAL O LOCAL AGENCY CD STATE -AGENCY <br />O CORPORATION O PARTNERSHIP Q COUNTYAGENCY O FEDEMLAGENCY <br />CITU NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ boxbiMis#a 0 INDIVIDUAL 0 LOCAL -AGENCY O STATEAGENCY <br />CORPORATION O PARTNERSHIP Q COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE#WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322.9669 it questions arise. <br />TY (TK) HQ 4 4- - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPI&TED) — IDENTIFY THE METHOD(S) USED <br />✓ CNbhkkaM I SELF-INSUREDO UARANTEE f� 3 INSURANCE (] d SURETY BOND <br />5 LETTER OF CREDIT 5 EXEMPTION Q 99 OTHER <br />V1. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unles x I or II is Checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. V it.D 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 B SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # FACILITY # <br />PP,Z 0 <br />LOCATION CODE- T CENSUST OL 9UPVISOR-DISTRICT -OP NAL <br />UPTIO 2 3 ! <br />Yy <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, uNLtSS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS ��0�)R <br />FORM A(393) '4C�,-1�7AA7 <br />