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• • eeSooN ° <br /> STATE OF CALIFORNIA W+ e <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w�� <br /> e <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT Q 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY S <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 \ NAME FOPERATOR <br /> VVJC�me+ c{cl ran cm VI iC 14� Scan <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 161 1pv st `-tFL-. <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA COD <br /> C,}A' r CA <br /> ✓ BOX <br /> TO INDICATE ORPORATION INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY 0 FEDERAL-A 3ENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O RESERVATION <br /> 1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> 3 FARM Q 4 PROCESSOR5 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) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME1 CARE OF ADDRESS INFORMATION <br /> �0-SA-( Ing <br /> MAILING ORSTREET ADDRESS ✓hox bNbkad O INDIVIDUAL 0 LOCAL-AGENCY I�STATE-A ENCY <br /> O ORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAI AGENCY <br /> CITY NAMESTATEE ZIP C 5 E 3 v PHONE#WITH AREA CODE <br /> L L`'C o <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa bintlkate D INDIVIDUAL Q LOCAL-AGENCY (] STATEA ENCY <br /> I�CORPORATION O PARTNERSHIP D COUNTY-AGENCY Q FEDERA AGENCY <br /> CITYNAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 O S' 7 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box blMlcaN [::] 1 SELF-INSURED [-12 GUARANTEE L�j a INSURANCE O#BURET, BONO <br /> E-1 5 LETTER OF CREDIT [::]6 EXEMPTION E::] W 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 chocked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.0 II. II. <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 B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY III, 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 GE OF SITE INFORMATIO NLY. <br /> FORMA(5-91) I FOR00�3A5 <br />