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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILfTY)SITE <br /> MARK ONLY 1 NEW PERMIT 1 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION [:] T PERMANENTLY CLOSED <br /> ONE ITEM <2 INTERIM PERMIT 0 a AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 1I€_— <br /> I. FACILITY/SITE INFORMATION 8,ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> NAME OF OPERATOR <br /> NEAREST CROSS STR ET PARCEL AIOPTIONAO <br /> CITY NAME I <br /> STACA <br /> 1 1 ZIP CODE SITE PHONE N WITH AREA CODE <br /> ✓ eox <br /> TO INDICATE O CORPORATION El INDIVIDUAL [::]PARTNERSHIP Q LOCAL-AGENCY 0 COUNTY.AGENCY' O STATEAGENCY' O FEDERAL.AGENCY' <br /> N owner d UST to a public n0 DISTRICTS' <br /> p agency,anplde the Idlowi name of Su rvior of dNlebn,saclbn,m office which operates the UST <br /> TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTOR <br /> .P.A. I.D.N fcplonag <br /> 3 FARM N PROCESSOR ORESERVATION <br /> OTHER ANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) HONE N WITH AREA CODE D : NAME LAST,FIRS <br /> —f ( T) _ PHONE N WITH AREA CODE <br /> N TS: NAME(LAST,FIR HONE N WITH A EA CODE N HTS: N ME(LAST,FIRST) PHON N WITH AREA CODE <br /> I s d1 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME y� CARE OF ADDRESS INFORMATION <br /> ..�49 1! 30I te <br /> MAILING OR STREET ADDRESS p ✓boa bindkale = INDIVIDUAL ,:0 LOCAL-AGENCY <br /> CORPORATION 0 PARTNERSHIP - FEDERAL-AGENCY <br /> CITY NAME <br /> PHONE# ETN AC FEDEMLAGENCV <br /> S`i d 2 STATE ZIP COD PHONE N WIT AREA CODE <br /> �o -a <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa biMbate <br /> INDIVIDUAL Q LOCAL-AGENCY 0 STATE-AGENCY <br /> CITU NAME D CORPORATION E�] PARTNERSHIP COUNTY AGENCY FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE N WITH AREA CODE <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 bintlkate Q I SELF-INSURED E::]2 GUARANTEE ED?INSURANCE <br /> LETTER OF CREDIT 6 EAEMPTION (]d SURETY Ng <br /> OTHER / <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless x 1 or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. IL III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTEDS SIGNED) OWNER'S TITLE DATE MONTH/DAVNEAR <br /> LOCAL AGENCY USE ONLY 7e <br /> COUNTY a JURISDICTION Al FACILITY! <br /> LOCATK7N CODE -OPTIO� CENSUS TRACTN OPTIONAL 9UPVISOR-DISTRICT CODE -G1�Ip� <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(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />