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i <br /> STATE OF CALIFORNIA ` <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> 7J:Jam/ UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> ' <br /> /fpl/Nf <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION7 PERMANENTLY CLOSED SITE <br /> ONE REM E] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> O FACILITY NAM FOPEIiATOR n_ <br /> AD ESS N STCRgS$STREE'FT PARCEL#(OPTIONAL) <br /> CITYN q_ TATE ��,(LLLlZpJIP-- ff///"��E�6L17 SITE PHONE N WITH AREA CODE <br /> ✓ eoz <br /> T�j(J/syl ca ` 7p3 <br /> TOINdCATE CORPORATION O INDIVIDUAL =1 PARTNERSHIP LOCAL-AGENCY Q COUNTY AGENCY STATE AGENCY =1 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION O 2 DISTRIBUTOR -/ IF INDIAN #OF TAN AT SITE E.P.A. I.D.xWfi°nap <br /> RESERVATION <br /> Q 3 FARM O 4 PROCESSOR [/5OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME( AST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxbintlkaB 0INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> D CORPORATION Q PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CIN 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 /> MAILING OR STREET ADDRESS ✓ boa b WIcals O INDIVIDUAL LOCAL-AGENCY (] STATE-AGENCY <br /> 0 CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ [4—F4 -F�� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP ED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Eoa bnkkale O I SELF4NSURED 2 ARANTEE 0 3 INSURANCE [-14 SURETY BOND <br /> O 5 LETTEROFCREDIT LW <br /> E%EMFRON 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: I.n II.❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILrrY# <br /> 81 V,CID/IQ y r � <br /> LOCATION OPTIONAL ICENSUS TPAG�-0-p I <br /> }PTI 6 SUPVISOR-D�WDE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS ISA SITE INFORMATION ONLY. <br /> FORM A(12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE T NK REGULATIONS <br /> FORW33A <br />