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0un �. <br /> • STATE OF CALIFORNIA 16 <br /> ``+. <br /> STATE WATER RESOURCES CONTROL BOARD �e <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W�� =s <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY r7 I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM E 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTONAL) <br /> W//✓ <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> I/ Box <br /> TOINDC TE CORPORATION Q INDIVIDUAL Q PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY ED STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTORQ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY : NAME(LAST,FIRST) / PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> 14<u IP- <br /> NIG 7 : AME( AST,FIRST)r_jprio (J~/ IHPHO`�E IT)ZlHA3FCODE / NIGHTS: N i( T,FIRST) FAX` <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa 0indicate 0 INDIVIDUAL Q LOCAL AGENCY Q STATE-AGENCY <br /> 0 CORPORATION = PARTNERSHIP COUNTY-AGENCY ED FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa 0 wicak INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questlons arise. <br /> TY(TK) HQ F4-T4-1- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa niMkate = I SELF-INSURED Q 2 GUARANTEE 0 3 INSURANCE O A SURETY B D <br /> =5 LETEROFCREDT 0 6 E%EMPnON 0 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: I.❑ II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PAIN TED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL (CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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) FOR0033A-5 <br />