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STATE WATER RESOURCES CONTROL BOARD � o <br /> NDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A c z �� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �yoo4 < <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT Ej 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> A FACILITY yAAE 5 I _,,l J �� NA OPERATOR <br /> ADDRES {/y L� -I/)�y',O/C. NEAREST SSTR ET PMCELM(OPr10NAU <br /> GINAME e / U STATE ZIP CODE SITE PHONE WITH AREA CODE <br /> �,fOT'/''� CA <br /> TO INDICATE O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP E::] LOCAL-AGENCY COUNTY AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> DSTRICTS <br /> TYPE OF BUSINESS 0 1 GAS STATION = 2 DISTRIBUTOR -/ IF INDIAN •OF TAN AT SITE E.P.A. I.D.M(optical) <br /> RESERVATION <br /> 0 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE;I WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE aWITH AREA rnnF _ <br /> NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA COD <br /> II. P 0PERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NA CARE OF ADD SS FORMAT <br /> MAILING EXR ' / ✓ hor blMkab(/ INDIVIDUAL 0 LOCAL-AGENCY Q SLATE-AGENCY <br /> O CORPORATION 0 PARTNERSHIP 0 COUNrY-AGENCY O FEDERAL-AGENCY <br /> CI NAM e}I STATE 21PPHONE N WITH AREA InODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS- ✓ box blWkm 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE IF WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO L4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP ED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box biMkale D I SELF INSURED =,ZtUARANTEE 0 3INSURANCE 0 4 SURETY BOND <br /> = 5 LETTER OF CREDIT OVII EXEMPTION 0 IN OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II' hecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.L-1 II. U. <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) APPLICANTSTITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY ft JURISDICTION n FACILITY x <br /> 39; r✓r� -> I V' <br /> __ - I --- - <br /> LOCATION C D -OPTIONAL iCENSUSTRACTJL- ri AA) SUPVISOR-DIS C DE - ZONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION 0 LY. <br /> FORM A02 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 033AR6 <br />