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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATIONT PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT F74 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE /✓A7/ <br /> I4DBAO!nIVITY <br /> FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> AM "CA <br /> ORT ETPARCEL$(OPTIONAL) <br /> �D ��? /-� SITE PH NE 1 WITH A EA D <br /> ✓ X O CORPORATION 1 INDIVIDUAL O PARTNERSHIP O LOCAL'AGENCY E::] COUNTWAGENCY' O STATE AGENCY' O FEDEMI#GENCV' <br /> TO INDICATE DSTRICTS' <br /> If owner of UST is a public agency,complete the following:name of Supervisor of dive soctbn.or office which operates the UST <br /> V IF TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR E:] RESERVADTION #OF T S AT SITE E.P.A. 1.D.#(ophonaq <br /> ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-0010131 <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) <br /> PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRSn PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME r CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to Indicate = INDIVIDUAL O LOCAL-AGENCY (] STATE AGENCY <br /> ✓ CORPORATION 0 PARTNERSHIP COUNTY AGENCY D FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> f <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ hox bindkate INDIVIDUAL LOCAL AGENCY 0 STATE AGENCY <br /> CORPORATION PARTNERSHIP � COUNTY AGENCY FEDERAL <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP TED)—IDENTIFY THE METHODS) USED <br /> ✓ Eox biMkale 1 SELF INSURED <br /> ❑ GUARANTEE 0 31NSURANCE Ij 4 SURETY BOND <br /> 5 LETTER OF CREDIT EV 6 EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is hacked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ if.IV IN.❑ <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 6 SIGNED) OWNER'STITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> CO® P12-# JURISDICTION If FACILITY# <br /> 1 n n <br /> LOCATION COD - TIONAL CENSUS TRA94# -rNtLL 9UPVISOR-DISTRIC CODE -OPTIONAL <br /> j (f 3I ' <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, NLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE DERGROUND STORAGE TAN//(,REGGULATIONS FORom3AaT <br /> FORM A(393) h I/Jti� <br /> 0 \ �� I(// <br />