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STATE OF CAUFORNIA " <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM A w o <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> ❑ 1 NEW PERMIT F-1 <br /> 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] e TEMPORARY SITE CLOSURE <br /> ;ciTYNAME <br /> ITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> ILITY NAME NAME OF OPERATOR <br /> NEprRFSTfr/^p�OSS/ngg1T E PARCELCOP IDNAW <br /> ���lL S'%� / `- S�v <br /> STATECA= <br /> 11 BOX Q CORPORATION LJ.INDIVIDUAL f�PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS' <br /> N owner d UST Is a public agency.complete the following:name of SupeNsor of OW'sbn,section,or duce which operates the UST <br /> TYPE OF BUSINESS O t GAS STATION 2 DISTRIBUTOR Q ,/ IF INDIAN #OF TANKS AT SITE E.P.A 1.D.#(apllanN) <br /> O RESERVATION 1 <br /> Q 3 FARM Q 4 PROCESSOR [1] 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> PHONE%WITHARFA CO E EDANAE(LAST,FI RST) PHONEEWITHAREACODEDAYS: NAME(LAST,FIRST) 9 �_NIGHTS: NAME(LAST,FIRST) PHONEx WITH AREA CODE AME(LAST,FIRST) PHONE CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME <br /> ✓ box b IFACAIe Q INDIVIDUAL = LOCAL-AGENCY Q STATE-AGENCY <br /> MAILING OR STREET ADDRESS <br /> ,f?_J< j j �CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL#GENCY <br /> STATE ZIP COD / PHONE#WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILINGOR STREET ADDRESS ✓box bsbbab Q INDIVIDUAL QLOCAL-AGENCY Q STATFEDERAGENCY <br /> �7". Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-PGENCY <br /> CITU NAME STATE ZIP CODE PHONE%WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ F4—F4--]- <br /> V. <br /> 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boxbWkaY Q I SELF-INSURED Q 2 GUARANTEE Q 3INSURANCE 0 4 SURETY BOND <br /> Q 5 LETTER OF CREDIT O 6 EXEMPTION Q 63 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: I.❑ I.[�D III.E <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 TITLE DATE MONTHIDAY7YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTYI % JURISDICTION# FACILITY# <br /> WYf5w ro v r -;X-v , <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# OP77ONAL eWISOR-CPTRCT CODE •OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR=3Aa7 <br /> FORM A(393) 0 <br />