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0 • <br /> l�gp xp <br /> STATE OF CALIFORNIA u i <br /> STATE WATER RESOURCES CONTROL BOARD 3` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> ,a> . <br /> COMPLETETHIS FORM FORE FACILITYISITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE (6 <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBAORF ILITYNAME NAME OF OPEF�OTQR Mad <br /> el ©/1 OSS S/L//1/!(/`O/�1', PARCEL#(OPfIONAq <br /> ADDRES NEAREST CROSS STREET <br /> 15— NAVY Dry v� <br /> CITY NAME STATE ZIP COgG / SITE PHONE N WITH AREA CODE <br /> S CA l <br /> TOOI/ Box INDICATE O CORPORATION INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(WlionalJ <br /> ❑ ❑ RESERVATION <br /> O 3 FARM O 4 PROCESSOR O S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> r <br /> NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> a WITH AREA CODE <br /> : NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> pwnmp <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> CAPE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING OR STREET ADDRESS ✓ box bindkale OINDIVIDUAL Q LOCAL-AGENCY D STATE-AGENCY <br /> Q CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> MAILING OR STREET ADDRESS ✓ box 0101019 E-1 INDIVIDUAL Q LOCAL AGENCY Q STATE-AGENCY <br /> CORPORATION E-1 PARTNERSHIP 0 COUNTY-AGENCY 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 F4-F4 - lLLLJ�l�7J �J <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ 0 I SELF INSURED :]71 <br /> UAFIANTEE LJ ]INSURANCE I�4 SURETY BOND <br /> box bindkate <br /> 5 LETTEROFCREDIT 6 EXEMPPON (] 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ IL❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED a SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIVEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPV L CENSUS TRACT# -OPP LJL SUPVISOR-DISTRCT CODE -OPTIONAL <br /> yr Y <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS AE OF SITE INFORMATION 0 6037A s <br /> FORM A(5-91) F <br />