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t UR ± Co <br /> STATE OF CALIFORNIA : s <br /> STATE WATER RESOURCES CONTROL BOARD 3W V = o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> �Y . <br /> • C�Llrp Kt..� <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY Q 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F:] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM El 2 INTERIM PERMIT Q 4 AMENDED PER 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FY41TY NAME_ C] NAME OF nATOR t <br /> ADDRES !� • NEAR SF CROSS REST PAA EJ(OPTIONAL) RE <br /> 7 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AA CODE <br /> CA <br /> TO INDICTE C]CORPORATION 0 INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY <br /> f� STATE-AGENCY OFEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Q 1 GAS STATION Q 2 DISTRIBUTORRESERVATION <br /> ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT ERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NE*WITH ARE A CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE 4Y WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 11. PROPERTY OWNER INFORMATION MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to}ndicale INDIVIDUAL l ] LOCAL-AGENCY STATE-AGENCY <br /> []CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCYQ FEDERAL-AGENCY <br /> CITY NAME STATE ZiP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE MPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to Indicate 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACC UNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)--IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 0 1 SELF-INSURED =2 GUARANTEE Q 3 INSURANCE <br /> []4 SURETY BOND <br /> 0 5 LETTER OF CREDIT 0 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 11 is checked. <br /> [HK:0N:E BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I,E II.❑ lit. <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&SIGNATURE) APPLICANTS TITLE DATE MONTHJDAY1YEAR <br /> LOCAL AGENCY USE ONLY <br /> C�OjUNTY# gg­ <br /> JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR�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 /> FORM A15-91) <br /> FDR0033A-5 <br />