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A � � 'tZOUR I•x<, <br /> STATE OF CALIFORNIA x° <br /> i STATE WATER RESOURCES CONTROL BOARD w o <br /> 7 0 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A • c.`If �,'• <br /> � A <br /> / ' 1 NEPERMIT COMPLETE THIS FORM FOR EACH FACILRY151T O 7 PERMANENTLY CLOSED SITE <br /> LY 0 6 TEMPORARY SITE CLOSURE 01 <br /> 3 RENEWAL PERMIT D 5 CHANGE OF INFORMATION <br /> W <br /> MARK ONA AMENDED PERMIT <br /> ONE ITEM 2 INTERIM PERMIT <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BECOMPLETEDEOFOPERATOR <br /> DGAOR FACILITY NAME CELM(OPTIONAL) <br /> NEAREST CROSS STREET <br /> ADDRE S SITE PHONEM WITH AREA CODE <br /> D 111: 4 STA E IP CODE O <br /> CITY A E "I <br /> AL AGENCY COUNTYAGENOY Q STATE-AGENCY 0 FEDERAL-AGENCY <br /> ✓ Box CORPORATION 0 INDIVIDUAL I0 PARTNERSHIP l�LOC <br /> DISTRICTS <br /> TOINDICATE V IF INDIAN MOF TANKS AT SITE E.P.A. I.D.M(oplianap <br /> TYPEOFSUSINESS 1 GAS STATION Q 2 DISTRIBUTOR RESERVATION V <br /> 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRs� (a Oti If <br /> ST. RST) <br /> PHO EM WITH AREA CODE /VL /-' <br /> DAVM ( ^ <br /> �J NIGHTS: NAME(LAST.1-11-tel) r � <br /> _ PHONE M WITH AREA CODE <br /> NIGHTS: AME A FI T) I I �a0� <br /> II. PROPERTY OWNER INFORMATION• USIT BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME LOCAL-AGENCY Q STATE-AGENCY <br /> ,/ box blMmaN �INDIVIDUAL <br /> MAILING OR STREET ADDRESS Q CORPORATION O PARTNERSHIP ED CONE AGENCY ARE= FEDERAL-AGENCY <br /> STATE ZIP CODE <br /> DE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION (MUST BE CO LETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OWNEDSTATE AGENCY <br /> ./ box miMicam INDIVIDUAL LOCAL-AGENCY <br /> MAILING OR <br /> FEDERAL AGENCY <br /> STREET ADDRESS CORPORATION Q PARTNERSHIP O CO %GIC <br /> STATE ZIP CODE OEWH AREA <br /> _CINAM <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE AC OU T NUMBER-Call(916)323-9555 it questions arise. <br /> TY(TK) HQ L-414] <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE MES NODES) USED O e suRE veoND <br /> 0 2 GUARANTEE <br /> O I SELF INSURED O 6 EXEMPTION �] <br /> 92 OTHER <br /> box to mft.la 5 LETTEROFCREDT <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unlleeesss box I or[:-] <br /> r 1❑1 s checked. <br /> CHECK ONE BOX INDICATING <br /> WHICH ABOVE ADDRESS d. <br /> S SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> D CORRECT <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,0 ERUEA Mot DAVIYEAR <br /> APPLICANTS TITLE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY 40 FACILITY <br /> # L <br /> COUNTY M JURISDICTION M <br /> ISUPVISORDISTRICT CODE-OPTIONAL <br /> LOCATIO IE -O T-D AL CENSUS{ CTM -OPTIONAL <br /> ION- FORM B,UNLESS THIS IS A ,,,'I�v OF SIT <br /> MATI <br /> THIS FORM MUST BE ACCFILMPA FORM WITH THE LOCAL AGENVRE Eh7PLEMENTINGRMIT APPLICATTHE UNDERGROUND STORAGE TANK REGULATIONS INFOR <br /> FORM A(129:1 � 4_e <br />