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Px'e�u.�t x'p <br /> r STATE OF CALIFORNIA 'y <br /> STATE WATER RESOURCES CONTROL BOARD +�„� v <br /> C UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A e <br /> ,.ana,• <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT = 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE Dz' <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> r <br /> R FACILITY NAA , _ _T NAME 0F.QPEf1ATOR <br /> Lw /V/x Al . <br /> / �/y{���y NEAREST CROSS STREET CEL#(OPTIONAL) <br /> D F7 N / / e � /{LJO/l <br /> CITV[�/yAME / STATE ZIPCODEO SITE PHONE#WITH AREACODE <br /> L/Y7/I1(I�(`�`;� CA 5 <br /> BOX <br /> TOINDIIC TE O CORPORATION INDIVIDUAL O PARTNERSHIP 0 DO AL-AGENCY O COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> ICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR E�:] IF INDIAN RESERVATION #OF TA T SITE I E.P.A. I.O.#(optional) <br /> O 3 FARM O 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CON ACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) *WITH AREA GQnP <br /> PHONE#WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b indicate Q INDIVIDUAL 0 LOCAL-AGENCY I= STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY l= FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindb O INDIVIDUAL Q LOCAL-AGENCY O STATE-AGENCY <br /> O CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZA�TIOON�LIST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4 4 - 1— <br /> V, PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COM ETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box biMbate = I SELF-INSURED =JAGUARANTEE L_j 31NSURANCE 0 4 SURETY SONO <br /> O 5 LETTER OF CREDIT EV6 EXEMPTION 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.O IL 7 H.F <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION C E OPTIONAL CENSUS TRACT# -OPj,IOONNAL 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 />