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gOVR : C <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A v o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 1 3 RENEWAL PERMIT E 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM El 2 INTERIM PERMIT O 4 AMENDED PERMIT = 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBARF CILITY NAME V/ <br /> NAMEOFOPERATOR <br /> ADDRESS AREST CROSS STR <br /> Ex <br /> PRCELN(OPTIONAL <br /> CI <br /> , STATE ZIP DE SITE PHONE M WITH AREA CODE <br /> S`f CA <br /> I/ BOX <br /> T NDIIC TE COO RATION (] INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY COUNTY AGENCV <br /> DISTRICTS O STATE AGENCY D FEDERAL AGENCY <br /> rP71=BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN q OF TA AT SITE E.P.A. I.D.M(optimal) <br /> 0 *17 <br /> 3 FARM 4 PROCESSOR 5 OTHER 0 RESERVATION <br /> O OR TRUST LANDS <br /> EMERGENCY CONTACT PER N (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) ONE P WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PH E x WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUS BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box blMbale I1 INDIVIDUAL l= LOCAL-AGENCY O STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLET ) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxbiWicate (] INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> CITU NAME O CORPORATION = PARTNERSHIP (]COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE 0 WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUM ER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ a F4 - <br /> 3 al <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate 1 SELF-INSURED Q 2 GUARANTEE L—] 3 INPRANCE <br /> D 5 LETTEROFCREDI D 4 SURETYBOND <br /> (]8 EXEMPTION 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[7] it.O III. <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 MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTYp JURISDICTION <br /> L—_W # FACILITY It <br /> f`L'-l'�11-(7FTII <br /> LOCATIONCODE -OPTIONAL CENSUS TRACTp -OPTIONAL SUPVISOR.DISTRICT CODE -OPTIONAL <br /> SS <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE t4FORMATION ONLY. <br /> FORM A(5-91) <br /> IFOR0033A 5 <br />