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teyouw e. <br /> STATE OF CALIFORNIA r' °>< <br /> STATE WATER RESOURCES CONTROL BOARD w mom, e <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e <br /> COMPLETE THIS FORM FOR EACH FACILfTYISITE <br /> MARK ONLY ❑ EW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERNA NT Y SITE <br /> ONE ITEM 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE Q <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME 1� r NAME OF OPERATOR <br /> F UE <br /> ADDRESS NEAREST CROSS STREET PARCEL (OPTIONAL) <br /> oK94h <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> A' CAv BOX <br /> S 3 <br /> T NDICATE 0 CORPORATION (] INDIVIDUAL =PARTNERSHIP []LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DIST <br /> TYPE OF BUSINESS ❑ I GAS STATION 2 DISTRIBUTOR ❑ q SERVATION #OF TANKS AT SITE E.P.A. I.D.#(oPlianap <br /> O 3 FARM O A PROCESSOR 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) PHONE 4 WITH AREA CODF <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRESS ✓box bin ik E-1 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> (]CORPORATION = PARTNERSHIP E-1 COUNTY-AGENCY O FEDERALAGENCY <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 ✓ mi b Indkm = INDIVIDUAL D LOCAL-AGENCY (]STATE-AGENCY <br /> O CORPORATION E=1 PARTNERSHIP COUNTY-AGENCY O FEDERAL AGENCY <br /> CIN NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD F0ALIZNN USFEE ACC NUMBER-Call 235 if questions arise <br /> W 7d0TY(TK) HO 4 � S� , <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box m iMkale C I SELF-INSURED 2 GUARANTEE0 J(NSU CE [] /SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION THER <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: L❑ II._ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION a FACILITY# <br /> LOOATIONCODE -OPTIONAL (CENSUS TRACT# -OP / `SUPVI R-DIST TCODE -OPIMNAL <br /> THIS FORM MUST BE XCCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATION <br /> (J'/%j� FOROOJ3Afl6 <br />