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a <br /> STATE OF CALIFORNIA • <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY f NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 B TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORF ILITY NAM NAME OF OPERATOR <br /> ADDRESS <br /> /J NEAREST CROSS STREET PARCELaIOPTM)NAU <br /> C TY ZAMff STATE ZIP CODE TEP NE a WITH AREA CODE <br /> ✓ <br /> CA �5 3� Z <br /> BOX <br /> TOINDICATE O CORPORATION INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY• lD STATE-AGENCY' ED FEDERALAGENCY' <br /> It owner of UST Is a public agency,complete the tolioWn :name of 3 OGTRICTS' <br /> e upervkor of tlNkbn,secibn.a office Which operates the UST <br /> TYPE OF BUSINESS Q f GAS STATION Q 2 DISTRIBUTOR / IF INDIAN <br /> ESSOR a OF TANKS AT SITE E. <br /> 0 3 FARM 4 PROC5 OTHER O RESERVATION P.A. I.D.a(apNawe <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NA E( AST.FIRST) HONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> 170 7ZJ— 75 <br /> NIGHTS: NA E(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE x WITH AREA CODE <br /> II. PROPERTY OWNER I ORMATION- MUST E COMPLETED <br /> NAME CAREOF ADDRESS INFORMATION <br /> MAILIN(GJ.pR STREET ADDRESS '/bo'"'cate = INDIVIDUAL =LOCAL-AGENCY <br /> r 0 Z __ 0 CORPORATION =PARTNERSHIP [:DCOUNTYAGENCY 0 FEDERAL-AGENCY <br /> NCY <br /> CITU NAME STATE ZIP CODE PHON #WITH AREA CODE <br /> 5-7 <br /> j <br /> III. TANK OWNER I F RMATION-(MUSTB COMPLETED) <br /> TNA��OW R CARE OF ADDRESS INFORMATION <br /> . GYirr STREET ADDRESS boa bind INDIVIDUAL Q 2aO LOCAL-AGENCY O STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY O FEDEMLAGENCY <br /> STATE Z1P CODE HONE I WITH AREA CODE <br /> � Z37 � 7Z7-SS <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boa b Indicate = f SELF-INSURED (]2 GUARANTEE (] 3 INSURANCE <br /> ED (]99 OTHER <br /> 5 LETTER OF CREDIT O 6 EXEMPTION O a SURETY BONG <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 /> L O II. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND C&RECT <br /> OWNER'S NAME(PRINTED 8 SIGNED) OWNER'S TITLE <br /> DATE MONTWDAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY#Z ilf74��7 <br /> LOCATK)NCODE -OPTIONAL CENSUS TRCT# -rJPTIONAL 9UPD3THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE <br /> FORM A(SIBS) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> ib 0 FOROMWID <br />