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J <br /> STATEOFCAUFORMA ......ar <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ' a: <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> WanY` <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ <br /> ONE REl❑ 2 INTERIM PERMIT a AMENDED PERMIT <br /> ❑ 8 TEMPORARY SITE CLOSURE 7 PERMANENTLYf.LGSII <br /> 1. FACILITY/SITE INFORMATION 8 ADDRESS-(MUST BE COMPLETED) <br /> nPA nq FACILITY NPME <br /> 110 G NAMEOFOPERATOR <br /> ADDRESS u <br /> NEAREST CROSS STREET PARCEL Of(OPrpNAL) <br /> CITY NAME <br /> Sr�G STATE ZIP ODE Q SITE PHONE 0 WITH AREA CODE <br /> TO NdC TE O CORPORATION 0 INDIVIDUAL Q PARTNERSHIP � LOCAL-AGENCY (] COUMY.AGENCY' <br /> If amer W UST Is a public a K DISTRICTS' STATE-AGENCY• FEDERAL P agency,mnplete the follovAn :name of gu rvisar of tlN Ion,section,or office wCkh operates the UST <br /> TYPE OF BUSINESS ❑ T GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN i OFT�S AT SITE E.P.A. I.D.#(oplianaQ <br /> ❑ 3 FARM ❑ d PROCESSOR 5 OTHER ❑ RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•Optional <br /> DAYS.NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> TJ. kaloke� <br /> ) DA7NAMEAST,FIRST) PH777 ONE x WITH AREA CODENIGHTS: NAME(LAST,FIflST) PHONE#WITH AREA CODE NI (LAST,FIRST) <br /> PHONE x WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME- <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> ✓box bIntlkate 0 INDIVIDUAL ( J LOCAL-AGENCY <br /> O COflPoMT ON Ij STATE AGENCY <br /> CITY NAME PARSE <br /> COUNTY-AGENCY QFEDERAL-AGENCY <br /> - STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> Q,4, CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> ` 1box <br /> birdkale INDIVIDUAL 0 LOCALAGENC =0 STATE-AGENCY <br /> CITY NAME CORPoRATION 0 PARTNERSHIP �COUNrY-AGENCY FFDEMLAGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE­'ACCOUNTNUMBER-Call(916)0447uum if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box blMkaN I SELFINSUREO (]2 GUAflAMEE L-1 7 INSURANCE <br /> 175 LETTEROFCREDT Q 8 ExEMPnON Q gp OTHER O 1 SURE YBONO <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE Box INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> ._ L❑ IL❑ NL❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF <br /> MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED 8 SIGNED) <br /> OWNER'S TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY 1F� <br /> COUNTY# <br /> JURISDICTION �n , <br /> m " <br /> LOCATION CODE -OPTIONAL CENSUS TMCTi- <br /> O � OPTIONAL 9UPVISOR-DISTRICT CODE -ap <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPUCATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A..(3M) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> /L� ! LC I � cel v:" • J l L( �j��4G�(1 • FGRorosAHT <br />