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eW^ P <br /> STATE OF CAUFORNIA Aa a <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A :m� <br /> a / , oa <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE o�„na,,,�- <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 0 6 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT 0 4 AMENDED PERMIT O a TEMPORARY SITE CLOSURE •--7 <br /> J 7 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS ST}EETT PARCEL#(OPTIONAU <br /> GAS PFJ <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Gore cAV BOX �Szyo <br /> TO INDICATE O CORPORATIONINDIVIDUAL 0 PARTNERSHIP � LOCAL-AGENCY <br /> COUNTY-AGENCY' O STATEAGENCY' � FEDERALDISTRIC <br /> N canner d UST la a public agency,corrplde the follow g:name of SNPONleor of tlNlkbn,seclion,or office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#rnpecnat; <br /> 3 FARM 4 PROCESSOR 5 OTHER O RESERVATION 1 <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-OPllonal <br /> DAYS: NAME( T,FIRST)r,L PHONE#WITH REA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> i � 1 33Z3S <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 3r�L r r� <br /> MAILING OR STREET ADDRESS ✓ ..I.bals D INDIVIDUAL Q LOCAL.AGENCY STATE-AGENCY <br /> ED CORPORATION Ij PARTNERSHIP E-3 COUNTY AGENCY E:j FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE <br /> PHONE#WITH AREA CODE <br /> Gx�017__ c=7 o <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS✓ boa biMbale L--j INDIVIDUAL LOCAL AGENCY 11 STATE AGENCY <br /> Gf%• /�-..'— 'S% O CORPORATION I__1 PARTNERSHIP ED COUNTY AGENCY Il FEDERAL AGENCY <br /> CITY NAMESTATE 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 [4-F41- <br /> V. <br /> 44- -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bbCbals 0 1 SELFINSURED L�]2 GUARANTEE ED 3 INSURANCE <br /> 0 5 LETTEROFCREDIT O 6 E%EMPTION D 1 SURETYSONO <br /> 99 DTNEfl <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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 1.❑ 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) OWNER'S TfrLE DATE MONTWDAYfYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> /La/s <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#OPTIONAL SU;'!A OjSTRICT CODE -OPTAOAW. <br /> o Z�• � •Jj <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3x93) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />