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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> Y \ <br /> COMPLETE THIS FORM FOR EACHFACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION 7 PERMANENTLY LOBED <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT a TEMPORARY SITE CLOSURE .. <br /> I. FACILfTY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBAOR FACILITY NAME NAME OF OPERATOR / <br /> ADDRESS NEAREST CR SSS REEr PARCEL I(OPTIONAU <br /> CITY NAME STATE ZIPSITE PHONE A WITH AREA CODE '301 <br /> CA <br /> I/ BOX <br /> TO INOICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY 0 STATE-AGENCY Q FEDERAL,AGENCY V <br /> DISTRICTS Y <br /> TYPE OF BUSINESS G' 1 GAS STATION ❑ 2 DISTRIBUTOR RESERVATION s OF TANKS AT SITE E.P.A. I.D.s(EpfiML) <br /> 3 FARM C < PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> OAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE S WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> PWn.NF f <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILNG OR STREET ADDRESS ✓ wxt� L[—, INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERALAGENCY <br /> CITE NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) ' <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ mxMaecals Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNrYAGENCY O FMERAL"AGENCY <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ nlnli[sY Q I SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q A SURETY BOND <br /> O 5 LETTER OF CREPT Q 6 EXEMPTION Q N OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or HIS checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.Q It.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APP4CANTS NAME(PRINTED L SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY s /-�,� JURISDICTION;e FACILITY* <br /> -/ <br /> LOCATION CODE -OPTIONAL CENSUST P.PT SUPVISOR-DISTR -OF TAONAL <br /> 2 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5911 / FOROOOBA-5 <br /> l ti <br /> lai v/ <br />