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• • aeW^ e <br /> STATE OF CALIFORNIA =� <br /> �o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH ACILITYISITE `"�•�^"'� <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILTTYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAO FACILITY NAMENAME FOPERATOR <br /> ADDRESS I NEAREST CROSS STREET <br /> AA PARCEL#(OFHONAU <br /> l <br /> CITU f�lAl/E STATE ZIP CODE SI PHON WITH AREA CODE <br /> Il/�/ CA 2dy 982 <br /> TO INDlux ICATE D CORPORATION O INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY [-3 COUNTY AGENCY' (]STATE-AGENCY' FEDERALAGENCY' <br /> DISTRICTS' <br /> 1 oanar W UST Is a public agew.mnplate the following:name of Supervisor of division,section,or office Whkh operates the UST <br /> TYPE OF BUSINESS t GAS STATION ❑ 2 DISTRIBUTOR0 ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.#loPlia l? <br /> RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR ❑ 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:;NAMEAST,FIRST) PHONE#WITH AREA CODE Z- 1NI H S: NAME(LAST,FIRSPHONE#WITH AREA CODENIGHT (LAST,FIRST) PHONE#WITH AREA CODE <br /> la <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NACARE OF ADDRESS INFORMATION <br /> MAILING OR STRE DRESS -/ ooa lo Indicate INDIVIDUAL I� LOCAL O STATE <br /> M717 alP E:1 CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY O FEDERALAGENCY <br /> CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> — <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NA E FOWNER CARE OF ADDRESS INFORMATION <br /> V <br /> AILING OR STREET ADDRESS ✓ boa b indicate OINDIVIDUAL O LOCAL AGENCY STATE AGENCY <br /> j 11 42.e20 CORPORATION O PARTNERSHIP COUNTY AGENCY D FEDERAL AGENCY <br /> CI NAME STATE ZIP CODE PHONE#WITH AREA CO E <br /> IV,BISARID OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 D <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa to Indicate L-1 1 SELF INSURED [D 2 GUARANTEE [::] 3 INSURANCE 4 SURETY BOND <br /> E-1 5 LETTEROFCREDT O 6 EXEMPTION E:1 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,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNERSTITLE DATE MONTHIDAY/VEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ® L��=i <br /> LOCATIONTIONAL CENSUS TRACT# -OPTIONAL BUPVISOR-DISTRICT CODE -OPTIONAL <br /> OP <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS S A CHANGE OF srrE#FbRmAtm ONLY. <br /> FORM A ISM) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUJTORAI TANK REGULkTKm <br /> � FpIga37AA7 <br />