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0 go <br /> 446 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , <br /> COMPLETE THIS FORM FOR EACH FA "/SITE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION O PERMANEN SITE <br /> ONE REM Q 2 INTERIM PERMIT 4 AMENDED PERMIT E:1 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DSA OR FACILITY NAM NAME OF OPERATOR <br /> a <br /> ADDRESS �&3 NEAREST CROSS STREET PMC <br /> CITY NAME STATE ZIPU' SITE PHONE a WITH AREA CODEI/ BOX CAI -3--7j./:;' <br /> T NDICRTE O CORPORATION O INDIVIDUA PARTNER IP [:D LOCAL-AGENCY 0 COUNTY AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> ' d UST lea public <br /> DISTRICTS S' <br /> x owner <br /> P agency,complete the following:name of Supervisor of ONbkn,section,IS RICT which operates the UST <br /> TYPE OF BUSINESS Q 1 GAS STATION 0 2 DISTRIBUTOR ✓RESERVAIF INTION <br /> DIAN 1#OF TANKS AT SITE E.P.A. I.D.s rap Aorraq <br /> 0 3 FARM Q d PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bot b Indicate F-1 INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION I= PARTNERSHIP O COUNTYAGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bot bindicate INDIVIDUAL LOCAL-AGENCY ED STATE-AGENCY <br /> D CORPORATION D PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE 21P 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 [4_14j- <br /> V. <br /> `' 1''-I-� /qAj <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BECOMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓bot b Indicate ID 1 SELF INSURED 0 2 GUARANTEE [:j 3 INSURANCE O 4 SURETY BOND <br /> =5 LETTER OF CREDIT O 6 EXEMPTION =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: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTWDAYIYEAR <br /> J <br /> LOCAL AGENCY USE ONLY <br /> COUNTY u �/ /� JURISDICTION It FACILITY a / <br /> LOCATION COD -OPTIO L CENSUS TRACTa -21TIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FOR4 MUST BE ACCOMPANIED BY AT LEAST l)6R MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION 6NLY. <br /> FORMA(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FCR0033AF' <br /> I_ <br />