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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A o <br /> C•ll•p<M• <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT D 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME (.( NAMEOFOPERATOR <br /> ADDRE(/SSS/' Gc, NE$T CRO ST ET PMCEl;ry0PfI0NAL) <br /> 1 a 4LCwJ <br /> CITY NAME + • STATE ZIPC DE SI1ryPo 3 �_ <br /> WITAREA H <br /> BOX <br /> TO INDICATE [--1 CORPORATION INDIVIDUAL PARTNERSHIP 0 LDCAL-AGENCY (]COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS = t GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN 14 OF TANKS AT SITE E.P.A. 1.D.x(optimal) <br /> RESERVATION <br /> O 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#W H AREA CODE DAYS: NAME(LAST,FIRST) PHONE I WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONEx WIT AREA CODE I NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA COQP <br /> II. PROPERTY OWNER INFORMATION• MUST BE MPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindkal# Q INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION = PARTNERSHIP Q COUNTY AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE x WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box binCbale INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> I�CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE x WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST <br /> /STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ F4-F41- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box blrAlcab I�1 SELF-INSURED 0 2 GUARANTEE [] 3 1 RANCE [=14 SURETY BOND <br /> (]5 LETTER OF CREDIT =6 EXEMPTION OTHEfl <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: X 11.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUSTRACTx-O M L SUPVISOR-DIST!I 001E ,NAL <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 /> FOROW3A5 <br /> FORM A(5-91) <br />