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No - <br /> STATi OFCAUFOAMA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM A e <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> 1 NEW PERMIT <br /> MARK ONLY Q 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY <br /> ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT 0 s TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MU BE COMP ETED) <br /> DBAOR FACILITY E ME OF OPERATOR <br /> ADDRESS <br /> V0 EAREST CROSS STREET PAgCFJ.e(pprpHA1J <br /> CITY NAME STATE ZIP T SITE PHONE a WITH AREA CODE <br /> Box <br /> CA U <br /> TOINDIGITE E71CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNrY-AGENCY• E:1 STATE-AGENCY, O FEDEfW.#GENCY' <br /> N owner of UST Is a public agency,ceep a the fall :name d S DSTRCTS' <br /> owkp upervNor d dNMbn,SOCCOn,m Ofte WhICh operates the UST <br /> TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR <br /> O ✓ IF INDIAN <br /> a OF TANKS <br /> 3 FARM d PROCESSOR RESERVATION AT SITE E.P.A. I.D.t(apNmW) <br /> 5OTHERORTRUSTUNDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓EWb6ditik 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE AGENCY <br /> O CORPORATION O PARTNPRSHP =CDUNTYAGENCY O FEDERALADENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓Eos Ichkas O INDIVIDUAL 0 LOCAL AGENCY 0 STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP 0 COUNTY AGENCY 0 FEDERAUAGEWY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ,/(qs bkdkals O I SELF-INSURED O B GUARANTEE (]3 INSURANCE O 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 0 S EXEMPTION 0 ge 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: LD II.Q III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTYCF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'STITLE DATE MONT YIYEAR <br /> LOCAL AGENCY USE ONLY <br /> I7,--tCOUNTTY 0 JURISDICTION N .CGY2,9 LIJ# FACILITY• - <br /> a, 501113 <br /> LOCATION CODE -OPriONAL CENS T OPTIONAL 9UWISOR-DISTRICT -fW710NAL <br /> THIS FORM MUST BE ACCOMPANIED BY At LEAST(1)OR MORE PERMIT APPLICATION- FORM B,bNLEsS THIS IS A CHANGE OF SITE�p7�p�AE� 10111 ONLY Q <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGUI,A'f , <br /> FORM A139'3) _ III 1--I <br />