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STATE OF CALIFORNIA •''`oup ` co <br /> STATE WATER RESOURCES CONTROL BOARD "� , .o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITEc""°"" <br /> MARK ONLY I NEW PERMIT E] 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION 7 PERMANENT <br /> ONE ITEM O 2 INTERIM PERMIT SITE <br /> 4 AMENDED PERMIT � 6 TEMPORARY SITE CLOSURE Ise)l <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) C/ <br /> DBA OR FACILITY NAME ``'' NAME OF OPERATOR <br /> vtkie%i l CO, <br /> ADDRESS Y <br /> S4 NEAREST CROSS STREET PARCEL 0(OPTIONAU <br /> // <br /> CITY N E N STATE ZIP CODE / <br /> CA 61tl TE PHONE#WITH AREA CODE <br /> 1 <br /> T NDIC TE 0 CORPORATION INDIVIDUAL- �G GE <br /> Q PARTNEflSHIP 0 LOCAL-AGENCY 0 COUMYAGENCY Q STATE-AGENCY <br /> DISTRICTS FEDERAL-AGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.FA. I.D. (optimal) <br /> O 3 FARM 4 PROCESSOR OTHER O RESERVATION (^�^ <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CO�ACTPERSO�NN (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 /> NAME CARE OF ADDRESS INFORMATION <br /> MAILINGORSTRE TADDRES� AU� �� gw <br /> p�,aI /!, ✓ box blMicat 0 INDIVIDUAL Q LOCAL-AGENCY 0 STATE-AGENCY <br /> CIN NAME Cl �v �� �- PORATION Q PARTNERSHIP �COUMKAGENCY � FEDERALAGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> G/I cg <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box b Indicate <br /> O INDIVIDUAL = LOCAL-AGENCY Q STATE-AGENCY <br /> CITU NAME CORPORATION E-1 PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> 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 CAJ D I G l 7 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ------------------------------------------------ <br /> ✓ box b indicate 1 SELF-INSURED =2 GUARANTEE [-13 INSURANCE <br /> O 5 LETTEROFCREDIT =6 EXEMPTION 99 OTHER 0 4 SURETY BOND <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. <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 8 SIGNATURE) APPLICANTS TITLE <br /> DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FAACIILITY##� <br /> LOCATION CODE -OPTION�L ------FCENSUS TRACTA -OPTIONAL SUPVISOR- <br /> Z G DISTRICT CODE -OPTIONAL <br /> z-20 <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(B)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(5FO <br /> • FORODJ7tA6�� <br />