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• � , •-t6Wv ti <br /> !!/ STATE OFCALIFORWA .� c''� <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A n <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE `'��•oa+`• <br /> MARK ONLY Ot NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a T PERMANENTLY CLO <br /> ONE REM ,2 INTERIM PERMIT 0 6 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMP ETED) <br /> DBA OR FACIL /0 JV I NAMEOFOPERATOR - <br /> fi4BP \ <br /> _ ADDRESS- FI NEARESTCROSS STREET PARCEL/(OPTIONAL) <br /> 6 -3 <br /> CITY NAME_ _ STATE / ZIP CODE SITE PHONE s WITH AREA CODE <br /> TO✓INDICATE 0 CORPORATION INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' 11 STATE-AGENCY• Q FEDERAL AGENCY• <br /> DISTRICTS- <br /> H owner ct UST Is a public agency.cor plate The fo6owing:name of Supervisor of olvialon,secllon,or oaice which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR REIF INDIAN I OF TANKS AT SITE E.P.A I.D.I(epflwW) <br /> O ATON <br /> 3 FARM Q d PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) E PHONE I WITH AREA CODE 0W: NAME(LAST,F RST) -. PHONE s WITH AREA CODE <br /> NIBNTS: NAME(LAST.FIRST) `PHONE a WITH AREA CODE NIGHTS: NAME(VST,FIRST) PHONE I WITH AREA CODE <br /> .�, r , / / f 1 I <br /> 11. PROPERTY O N R COM <br /> NAME CARE OF ADDRESS INFORMATION <br /> I <br /> MAILING OR STREET ADDRESSI r ✓ Om binEiON 0 INDIVIDUAL O LOCAL O STATE-AGENCY <br /> t/ )fLQ,� CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY O FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE I WIT AREA CO <br /> ao ' �3-D-6! <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OFOWNER CARE OF ADDRESS INFORMATION <br /> S VT/ <br /> MAILING OR STREET ADDRESS ✓ Ooa beAkm 0 INDIVIDUAL O LOCAL AGENCY STATE-AGENCY <br /> O CORPORATION M PARTNERSHIP O COUNTY AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE I WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 7474- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ Eos binokale Q I SELF 2 GUARANTEE T I=CE A SURE�Y <br /> 1. <br /> EOOIT 6 EXEMPTION �D <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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II. IN. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED a SIGNED) OWNER'S TITLE DATE MONTWDAYNEEAR <br /> LOCAL AGENCY USE ONLY Q C XD a 3 c 5 /S <br /> COUNTYIF JURISDICTION a FACILITY O <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,UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(393) OWNER MUST FILE THE FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />