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• STATE OF CALIFORNIA emoo. °o <br /> STATE WATER RESOURCES CONTROL BOARD yB <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CL <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME �/��K NAME OPERATOR <br /> ADDRESS NEAATCROSS T�REQ PARCEL x(OP(OPTIONAL) <br /> yy/ Cv� E // <br /> CITY NAME STATE A ZIP CODE SITE PHONE#WITH AREA CODE <br /> e v <br /> 16!7/ <br /> .1 BOX <br /> TOINDIIC TE O CORPORATION DIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY <br /> DISTRICTS FEDERAL-AGENCY <br /> TYPE OF BUSINESS ❑ 1 GAS STATION 2 DISTRIBUTOR / IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> ❑ RESERVATION <br /> 3 FARM ❑ 4 PROCESSOR 0 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,FIRS'!) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME n �4 CARE OF ADDRESS INFORMATION <br /> MAILING ORSTRT/!ADDRESS ��J/��J (� /� /` ✓ bo+bintlkate INDIVIDUAL Q CY LOCAL-AGENCY Q STATE.AGEN <br /> tel// Z CORPORATION MPARTNERSHIP COUNrY-AGENCY El FEDERAL-AGENCY <br /> CITY NAMES/y��,,/ STAT ZIP CODE ! PHONE#WITH ARE-CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAM EyF OWNER `� CARE OF ADDRESS INFORMATION <br /> MAI{LiI�NJ—� vJD S /9L//!`JY�� �J'�• ✓ boX b IndUte INDIVIDUAL E-1 LOCAL AGENCY STATE-AGENCY <br /> O CORPORATION PARTNERSHIP Ell COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP C001F• PHONE#WITH AREA CODE <br /> G7 tw <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box blMicale 0 1 SELF-INSURED O 2 GUARANTEE O 7 INSURANCE <br /> D 5 LETrEROFCREDIT I=6 EXEMPTION O A SURETY BOND <br /> I�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: I.❑ II.❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,lS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 5i <br /> LOCATION CODE -OPTIONAL C§VSUS TRACT? -OPTIONAL SUPVISOR-CTWICT CODE -OPTIONAL <br /> THIS ORM MUST BE ACCOMPANIED BY/CAT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5.91) <br /> FORINg7 <br />