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IV <br /> STATE OF CALIFORNIA :° <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD3 ` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A '�� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °'��roe•`' <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT *°lIFORMATI�fN ❑ 7 PERMANENTLY CLOS ITE <br /> ONE REM 0 2 INTERIM PERMIT Q a AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> D AOR FACILITYNAME NAME OF OPERATOR <br /> A D E S NEAREST CROSS STREET PARCEL#(OPTIONA) <br /> CITU NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE O <br /> CA <br /> TO IN AC TE 0 COR ORATION ED INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O ME--]COUYAGENCY' O SrATE AGENCY' FEDIEERALLAMNCY' <br /> DISTRICTS' <br /> X owner of UST Is a Public agency.corrplge the following:name of Supervisor of division.section,or oNics which operates the UST <br /> TYPE OF BUSINESS 0 t GAS STATION 2 DISTRIBUTOR q SERVATION #OF TANKS AT SITE E.P.A. I.D.#(gNApaQ <br /> 3 FARM d PROCESSOR -F;.g 5 OTHER OR TRUST LANDS /1 All <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA(LACODE <br /> NTS: NAME ST,FIRST) ONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> N MECARE OF ADDRESS INFORMATION <br /> MAIL-IN&OR STREET ADDRESS ✓ soy bleu (] INDIVOUAL 0 LOCAL AGENCY 0 STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP 0 COUNrY-AGENCY D FEDEMLAGENCY <br /> CITY NAME STATE ZIP CODE P N/E/ WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ cos biMkale 0 INDIVIDUAL E=1 LOCAL AGENCY E=1 STATE-AGENCY <br /> CORPORATION O PARTNERSHIP O COUNTY AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-F4--]- <br /> V. <br /> 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ eor b9dkaH [::] 1 SELFINSURED 2 GUARANTEE 3 INSURANCE A SURETY BOND <br /> E=1 5 LETTER OF CREDIT O 6 EXEMPTION (] 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: 1.O 11.0 III. <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&SIGNED) OWNER'STITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY i <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT DOGE -OPT10NAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS HI A CHANGE OF SIZE TION ONLY. <br /> A(3A93) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />