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N i l s c4 F/4 R rn 4j <br /> +zwouaccs <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ��� Z <br /> • C�[1n vµN`� <br /> COMPLETE THIS FORM FOR EAC FACILITYISITE <br /> MARK ONLY [� 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT E::] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION &ADDRESS-(MUST BE COMPLETED) V <br /> DBA OR FACIL TY NAME /�y "[" NAME OF OPERATOR <br /> OGIear <br /> ADDRESS NEAREST CROSS ST EET 1 PARCEL#(OPTIONAL? <br /> � o�(U)q ae? <br /> CITY N / � STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CACa o o - d <br /> ✓ BOX <br /> TOINDiCATE CORPORATION INDIVIDUAL Q PARTNERSHIP 0 LOCAL-AGENCY Q COUNTY-AGENCY 0 STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR Q ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(oplional) <br /> RESERVATION <br /> Q 3 FARM L_j 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) (/ PHONE#WITH ARE1A COD')E7[ DAYS: NAME(LAST,FIRST} � ,oq)t31 `tkoo <br /> Ir '�"` � _ ` — � _Llf]NE�t WITH ABFA C:t�nF <br /> NIGHTS: NAME(LAS31.FIRST) PHONE WI H AREA CODE GHTS: NAME(LAST,FIRS <br /> PHONE I WITH ARPA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM o, CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL Q LOCAL-AGENCY Q STAT6AGENCY <br /> Q CORPORATION © PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATEZIP CODE RHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NA OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxto'indicate OINDIVIDUAL Q LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION Q PARTNERSHIP ® COUNTY-AGENCY [] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PWONE#WITH AREA GODE <br /> 1V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - (� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate Q 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE L 4 SURETY BOND <br /> F-1 5 LETTER OF CREDIT 6 EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> F <br /> CK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> r <br /> CANT'S NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY rt JUFiISDICTI{1N# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# - N L SUPV ISOR-DISTRICT CODQ- PTION& <br /> 22 2 3. �I <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, <br /> FORM A(5-91) <br /> •�� �� ��� FOR0033A-5 <br /> fv <br /> i <br /> i <br />