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• ocwccs cU <br /> STATE OF CALIFORNIA .S ` <br /> a <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> cs <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W�� va <br /> COMPLETETHIS FORM FOR EACH F ITYISITE <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT O A AMENDED PERMIT ❑ 5 TEMPORARY SITE CLOSURE qih <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMENAME OF OPERATOR <br /> �iX <br /> ! <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> DD w cE/v>`sL_ <br /> CITU NAME SCnA <br /> ZIP CODE SITE PHONE#WITH AREA CODE <br /> g'4a-„ 175_ 3(6 ao9 <br /> TOINDBOX ICPTE 0 CORPORATION 1 INDIVIDUAL Q PARTNERSHIP a LOCAL-AGENCY Q COUNTY-AGENCY 0 STATE-AGENCY FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS , GAS STATION 2 TRIBUTOR Q v' IF INDIAN #OF TANKS AT SITE E.P.A. I.0.0(optional) <br /> a O RESERVATION <br /> Q 3 FARM A PROCESSOR Q 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 /> 5Ps4 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> ,5-4C PHONE#WTH AREA COOP <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS I/ Eex 0 iMkate INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> Q CORPORATION PARTNERSHIP O COUNTY-AGENCY =1 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 /> MAILINGOR STREETAODRESS ✓ pOX0 wiGle INDIVIDUAL = LOCAL-AGENCY QsTATE.AGENCY <br /> 0 CORPORATION PARTNERSHIP I=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)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 /> ✓ WX WImIcam = I SELRINSUREO 0 2 GUARANTEE 0 PKRANCE d SURETYBOND <br /> =5 LETTER OF CREDIT =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 Dal is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L II.ID III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED 8SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY It 'dj(/EC,so of <br /> ® 1610 / 1b 3 Y <br /> LOCATION CODE -OPTIONAL CENSUS TRACTO^# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> air 7s'v <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION FONNLY. <br />