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a ��s <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A o <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE `'�•o•"" <br /> MARK ONLY t NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SIT <br /> ONE ITEM Q 2 INTERIM PERMIT F7 # AMENDED PERMIT 6 TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMENAME OF,EPIAmRA ^oa <br /> ADDRESS NEAREST CROSS STREET IIMJ G( PAfqIEL9jOPrIONAQ <br /> CITY NAME orSTATE ZIP CODE SITE PHONE WITH AR CODfr/ <br /> n/7n,�q iKJ/N, <br /> CA Ca o rJ <br /> ✓V 1 <br /> 1 T 10 AC TE Box CORPORATION 0 INDIVIDUAL O PARTNERSHIP (] LOCAL'AGENCY O COUNTY-AGENCY' El STATE-AGENCY' O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> N owner of UST It a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS O t GAS STATION 2 DISTRIBUTOR RES/ IF INDIAN I <br /> ERVATION #OF TANKS AT SITE E.P.A. I.D.i(apthWJ <br /> 3 FARM Q d PROCESSOR Q 5 OTHER OR TRUST LANDS I <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•opgaul <br /> DAYS: E(LAS FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> a e o d 0 3(0 - 5� <br /> NIGHTS: NAME(LAST,FIQUi� PHO E#WITHAREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ObbYdicab INDIVIDUAL LOCAL AGENCY 0 STATE AGENCY <br /> CORPORATION O PARTNERSHIP COUNTY-AGENCY 0 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 ✓ box loin6kat# O INDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE LP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓Wa bineeale 1 SELF INSURED = GUARANTEE 3INSURANCE O A SURETY BOND <br /> O 5 LETTEROFCREDIT 6 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: LK XI II.0 III.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED 6 SIGNED) OWNER'STITLE DATE MONTHNAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION 0 F <br /> LOCATION CODE - TIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISJpIC •OP.TICNAL <br /> Ole �) <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. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> �XForoAA(sxe FA,ORm TIqIUK- e wt-a.�aG i �( -I I- 9`f z- FOR9G11AT <br />