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i <br /> Pteou'•C Co <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� v <br /> C�tInOPNn <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION V7 PERMANENTLY CLOSED SS <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) ccclll <br /> D8A FACILITY NAME NAMEOFOPERATOR <br /> a ber fi <br /> ADDRESS a '6 NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> a <br /> CITY NAMEn STATE ZIP DE SITE PHONE#WITH AREACODE <br /> � 7_OP� CA <br /> ✓ BOX <br /> TOINDICATE O CORPORATION INDIVIDUAL 0 PARTNERSHIP D LOCAL-AGENCY O COUNTY-AGENCY O STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR = <br /> ✓ IF INDIAN #OF TANKS AT SITE E.P,A. I.0.#(optional) <br /> 3 FARM O5 OTHER RESERVATION <br /> 4 PROCESSOX.R _/J!7 <br /> ❑ O OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYSNAME(LAST,FIRS PHONE#WITH AREA COD VS: AME(LAST,FIRST) <br /> r► e o a <br /> NIGHIS: E(LAST,FIRST) PHONE# ITH ARE ODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA COnF <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMEn CARE OF ADDRESS INFORMATION <br /> t> he <br /> MAILING 01 <br /> STREETADDRESS ✓ boxNnftate O INDIVIDUAL IJ LOCAL-AGENCY O STATE-AGENCY <br /> =CORPORATION 0 PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITU NAM STATE ZIP C DE PHONE#WIT REA CODE <br /> cL. CA <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b Indicate 771 INDIVIDUAL LOCAL-AGENCY EllSTATE-AGENCY <br /> CORPORATION = PARTNERSHIP 0 COUNrYAGENCY =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 4L�_ I � <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box blMkate I SELF INSURED 0 2 GUARANTEE I] 3 INSURANCE 0 A SURETY BOND <br /> I� 5 LETTER OF CREDIT Q 6 E%EMPnON [-1 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.❑ II. III.❑ <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 MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY a 0 <br /> COUNTY# JURISDICTION# FACILITY# <br /> a..t-I-F <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DI TRICT 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 INFORM <br /> AT NLY <br /> FORM A(5-91) 9A.5 <br />