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• oun � <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD e9 <br /> G UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A °�� yo <br /> ., o <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY F-1 I NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION EV7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT ❑ 5 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> D$R�R ACILITYN <br /> AMEOFOPERATOD. ij <br /> AADOOR NEAREST CROSS STREET o'i-vl PARCEL#(OPTIONAL) <br /> CI NAME, ( I / STATE Zip(27, � SITE PHONE WITH AREA CODE <br /> �fm <br /> TO INDICATE/�O[C/.�,{1 CORPORATION � INDIVIDUAL � PARTNERSHIP 0 LOCAL-AGENCY 0 COU✓NTYY-AGENCY E�:] STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 1 GAS STATION 2 DISTRIBUTOR RE/ IF INDIAN <br /> A OF TANK AT SITE E.P.A. 1.0.#(optimal) <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WIT14 AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COT <br /> II. PROPERTYOWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boa m Indicate 0 INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boa mindmale 0 INDIVIDUAL O LOCAL-AGENCY (] STATE AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ 14R]-LV14�1-I-11-.� LTJ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa mindmab 0 1 SELF INSURED O GUARANTEE 0 3INSURANCE E�]a SURETY BOND <br /> 5 LETTER OF CREDIT 5 EXEMPTION = 99 OTHER <br /> 771 <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: L E] IL F-1 III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PR INTED&SIGNATU RE) APPLICANTS TITLE DATE MONTHDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# loMl JURISDICTION# FACILITY# 3 -3, 12"/, <br /> 6Mf-11-f 6161 . � V <br /> LOCATION CUr OPTIONAL CENSUS TRACTt -_OPTIONAL SUPVISOR-STRICT CODE -OPnOAL4L <br /> THIS FORM MUST BE ACCOMPANIED BY.AZT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0033A 5 <br /> v f `,I <br />