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C 0 0 � us <br /> I STATEOFCAUPONBA J' U'�o <br /> / STATE WATER RESOURCES CONTROL BOARD W.,�� .- <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A ,, <br /> COMPLETE THIS FORM FOR EACH FACILRY/SITE `'t��nR+`' <br /> MARK ONLY 0 I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED <br /> ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FAC ITY NAME //'-�� NAME OF OPE OR <br /> Ila JS LtH Z. GpySe A� - <br /> ADDRESS NEARESTPAfCEl4(OPfONAy <br /> aR <br /> J '/: Yh � <br /> CITY NAME STAZIP C r SS� yE I-3 A EA COD <br /> /S <br /> CA .S3 <br /> BD% b/ 5 <br /> TOINUCATE O CORPORATION INDIVIDUAL =PARTNERSHIP O ISgF1CY COUNTY-AGENCY' STATE-AGENCY• OFEDERAL-AGENCY•DTRCT <br /> It owner of UST IsapubAc age ,mrrpI!.the following:name of Supervisor of dNMbn,section,or o8ioe which operates the UST <br /> TYPE OF BUSINESS 7 GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.:1(apfiona# <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: N E(LAST,FIRST) PHONE#WITH AREA CODE GAYS: NAME LAST,FIRST) PHONE 4 WITH AREA CODE <br /> S C.'. w _ 5 3 o "s <br /> NIGHTS:NAME T,FIRST) PHONE#WITH AREA CODE NIGHTS: NAM T,FIRST) PHONE#WITHAREACODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM ^ CARE OF ADDRESS INFORMATION <br /> 1•.�(Jx/ <br /> MAILING OR STREET ADDRESS / ✓ box binskaW (] INDIVIDUAL O LOCAL STATE-AGENCY <br /> /1M -L QCORPORATION (] PARTNERSHIP COUNTY AGENCY FEDERAL-AGENCY <br /> CITYNAME STAT^ ZIPCODE PHONE S WITH AREA CODE <br /> III. TANK OWNE INFORMATION•(MUST BE COMPLETED) 7� <br /> NAMEO WNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bmbimicale INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> �,- CORPORATION PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bbdkato O I SELF-INSURED 2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 6 EXEMPTION IEj w 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: L❑ I.❑ IIL®� <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED B SIGNED) OWNER'S TITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# - <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM ABIOS) � 0 <br /> j/-L FOR0033AR7 <br />