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n � >UOOUw : Co <br /> STATE OFCALIFORNIA ^> t <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�`� ya <br /> COMPLETE THIS FORM FORE HFACILITYISITE <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 ❑ a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACILITY AfAE NAME OF OPERATOR <br /> N /C /✓Ci <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAU <br /> CITY NAME/07346 STATE ZIP CODE SITE PHONE N WITH AREA CODE <br /> N CI/ BOX CA <br /> T NDCATE O CORPORATION INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY FEDERAL AGENCY <br /> 06TRICTS <br /> TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR O ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> RESERVATION <br /> 3 FARM O 4 PROCESSOR 0 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) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHON <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CA E OF ADDRESS INFORM TION <br /> N�-e & e o N ones Eo <br /> MAILING ORSTREETADORESS ✓ bot bintlbtlA INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> aroFloor- 0 CORPORATION O PARTNERSHIP Q COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME _ ZIP CODE PHONE#WITH AREA CODE <br /> 5011 MC Sco STATE / <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME FOWNER `� CARE OF ADDRESS INFORMATION <br /> Q <br /> MAILING OR STREET ADDRESS ✓ Dot blMiC M Q INDIVIDUAL Q LOCAL-AGENCY O STATE AGENCY <br /> CORPORATION = PARTNERSHIP (]COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 0 WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. <br /> TY(TK) HQ 4 4 0 -�6Nk qb;,, d <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bintlbaM 0 1 SELF-INSURED 9 3AUARANTEE Q 3 INSURANCE 0 4 SURETY SONO <br /> 5 LETTER OF CREDIT US 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' hacked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 11.V 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 /> LOCATION CODE -OPTIONAL CENSUS T27; -OPTIONAL SUPVISOR-DISTRII;ZEE---OPTIONAL O/.Z3 9/ <br /> L`✓ G (� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. i <br /> FORMA(5-91) <br /> FORD033A-5 <br />