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• I#6�yn I <br /> i <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> ��11I0eM•• <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION T PERMANENTLY CLOSEDSITE <br /> ONE REM O 2 INTERIM PERMIT [:71 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILRYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED)of OPERATOR <br /> FADORESS <br /> E <br /> NEAREST CROSS ST EET PARCEL#(OPTIONAL) <br /> �� $TATE ZP CODE ./ SITE PHONE#WITH AREA CODE <br /> CA � `Y�///���,,,���,,, LOCALAGENCV 0 COUNTY-AGENCY' O STATEAGENCV' O FEDEIULAGENCY' <br /> CORPORATION ( L]df INDIVIDUAL PARTNERSHIP DISTRICTS' <br /> — \ <br /> II oxner W UST la a public agency,oeanPlete the Ioliming:narne of Supervisor of division,sectbn,or oflice which operates the UST <br /> ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR 0 RESERVATION <br /> 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> PHO E#WITH A A CODE DAYS: NAME(LAST.FIRST) <br /> PHONE#WITH AREA CODE <br /> DAYS: NAME(LAST, (RST) �QJ _ <br /> .7� PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME _ <br /> /G� C ✓ pox to Indicate INDIVIDUAL O LOCAL AGENCY [:1 STATE AGENCY <br /> MAILING OR STREET ADDRESS CORPORATION TNEASHIP COUNTY-AGENCY ED FEDERAL <br /> pAe � -c <br /> STA ZIP CODEPHONE#WITH AREA CODE <br /> CITU NAME G/ <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> / IfET <br /> ✓ pox b indicate INDIVIDUAL O LOCALAGENCY STATE AGENCY <br /> MAILING OR STREG ����/ Q CORPORATION AATNERSNIP COUNTY AGENCY FEDERAL <br /> l� STATE ZIP CODE PHONE a WITH AREA CODE <br /> CITY NAME �S2�1J <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ hox blMkale D I SELF INSURED 0 2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND <br /> ry b(Mbindicate <br /> 0 5 LETTER OF CREDIT 0 6 EXEMPTION 0 IS 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: 1.0 11. 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 8 SIGNED) <br /> OWNER'S TITLE DATE MONTWDAV/YEAR <br /> LOCAL AGENCY USE ONLY &L> 06-f5_6 70 Fr p 00 90 7 <br /> COUNTY# JURISDICTION <br /> LOCATION CGDE -OPTIONAL CEpS11ST C # -OPTIONAL SUQ-DISTRICT CODE -OPTIONAL <br /> O G3 J 7 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE HFOR ON ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND RAGE TANK REGULATIONS FORom3Am <br /> FORM A(393) <br />