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0 cWa e <br /> STATE OF CAUPORNA �� '� <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ^m '� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `���.ea+�' <br /> MARK ONLY F-1 1 NEW PERMIT F--j 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION III ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS ST EET PARCEL#(OPTIONAL) <br /> / <br /> CITY NAME STATE ZIP CODE SITE RHONE a WITH AREA CODE <br /> Box <br /> Gv/N CA �SZ�b <br /> TO INDICATE CORPORATION INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY O CWNrY-AGENCY' O STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> DISTRICTS' <br /> •N uvner of UST Is a public agency,complete the following:name of Supervisor of division.section.or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.It(opfwneq <br /> 3 FARM 4 PROCESSOR 6 OTHER RESERVATION <br /> O Oq TRUST LA <br /> RESERVATION <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIflST) PHONE a WqH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME / CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRES ✓ boX bVOICA# O INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> fl�(J GT/ -;IV— CORPORATION O PARTNERSHIP COUNTYAGENCY D FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> °c/G _ <br /> MAILING OR STREET ADDRESS - ✓bmickikate 0 INDIVIDUAL O LOCAL-AGENCY D STATE-AGENCY <br /> O <br /> CORPORATION 0 PARTNERSHIP (] COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> G / <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [4-]4--]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa bindkate E:I 1 SELF INSURED [:12 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> ED 5 LETTEROFCREOT ED 6 EXEMPTION (]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: 1.[1] I1 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 A SIGNED) OWNER'S TITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY It JURISDICTION IF FACILITY# �. <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVL40A-DISTRICT CODE -OPTIONAL <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(393) • . FOROX13Ai <br />