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Upcis <br /> STATE OF CALIFORNIA ...... <br /> STATE WATER RESOURCES CONTROL BOARD a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> �'•Sii pp H`' <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 ❑ 5 TEMPORARY SITE CLOSURE <br /> Of <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> �} CA 90g Y v <br /> ✓ BOX []CORPORATION [IJ INDIVIDUAL Q PARTNEPSHIF Ej LOCAL-AGENCY I] COUNTY-AGENCY' [] STATE-AGENCY' <br /> TO INDICATE DISTRICTS FEDERAL-AGENCY' <br /> If owner of UST is a public agency,complete the following, name of supervisor of dNis'ron,section or office which operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION 2 DISTRIBUTOR L] ✓IF INDIAN 1#OF TANK7ATSITE [EP. I.D.4(optional) <br /> RESERVATION <br /> ❑ 3 FARM 4 PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: Ni(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME{LAST,F ST) PHONE#WITH AREA CODE <br /> �Gds � /� <br /> NIGHTS: NAME(LAST,FIRST} PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate [:7INDIVIDUAL 0 LOCAL-AGENCY STATE'AGENCY <br /> O G- - �1' t�CORPORATION ED 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 y ✓ box to indicale INDIVIDUAL = LOCAL-AGENCY STATE-AGENCY <br /> (� G�h �.GL� =CORPORATION Q PARTNERSHIP = COUNTY-AGENCY Cj FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PH <br /> ONE 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 44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box 10 ii 0 1 SELF-INSURED Q 2 GUARANTEE 73 3 INSURANCE [_7 4 SURETY BOND ] S LETTER OFCREDIT <br /> Q 6 EXEMPTION O 7 STATE FUND <br /> 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND&CERTIFICATE OF DEPOSIT [= 10 LOGAL GOVT.MECHANISM E] 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 /> [CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 11.❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION# FACILITY# �— <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 /> FORMA(6.95) <br /> OWNER MUST FILE THIS FOROH THE LOCAL AGENCY IMPLEMENTING THE UNDERGR0 STORAGE TANK REGULATIONS <br />