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n�60JF [y <br /> STATE OF CALIFORNIA [s <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> O�M.n <br /> COMPLETETHIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE Z <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED <br /> D RF CILITY NAM NA OF OPERATOR <br /> 49 <br /> ADOR SS NEAREST CR04t STREET PARCEL#(OPTIONAL) <br /> � <br /> C STATE ZIP CO9p / SITE PHONE#WITH AREA CODE <br /> 11 <br /> TO INDICATE O CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY [:1 COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ / IF INDIAN RESERVATION #OF TANK.y AT SITE E.P.A. I.D.#(aptkYall <br /> O 3 FARM 4 PROCESSOR = 5 OTHER OR TRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE OAVS: NAME(LAST,FIRST) <br /> NIGHTS:NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box WIndkab, INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> Q CORPORATION O PARTNERSHIP O COUNTY-AGENCY FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME DF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADD RESS ✓ box blMkaN INDIVIDUAL D LOCAL-AGENCY O STATE AGENCY <br /> 0 CORPORATION O PARTNERSHIP D COUNTYAGENCY 71 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 14X_" ` _ "� t i <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP TED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box oindkat, O 1 SEUHNSURED M 2 ARANTEE 0 3 INSURANCE E=1 4 SURETYBDND <br /> O 5 LETTER OF CREDT EXEMPTION 0 99 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.❑ II. 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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 1 <br /> LOCATION CODE 6CWrL CENB STRACT SUPVISOR-DISTRIICT CODE -OPTIONAL 4 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SRE INFORMATION ONLY. <br /> FORM A(5-91) FOBOMA 5 <br />