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ar <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 O 1 NEW PERMIT F-1 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION EPI"7 PERMANENTLY SE ET <br /> ONE ITEM O 2 INTERIM PERMIT E:j 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA VACUITY NAME NAMEOFOPERA R <br /> ADDR S� B / o� NEAREST CROSS STREET PARCEL#(OPTIONAL) LJ <br /> CITY NAM8LS STATER ZIP GODE__ H N <br /> SIT E/I WITH FA C <br /> van- C <br /> ✓BOX Q CORPORATION Q INDIVIDUAL [71IDUAL I� PARTNERSHIP Q LOCAL COUNTY-AGENCY' STATE AGENCY' 0 FEDODERA_-AGENCY' <br /> TO INDICATE DISTRICTS <br /> &ownmol USToapublicagewy.compete the following:name of smamn rof&isun,section oraXke WhO openates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR 0 RESERVATION <br /> INDION X OFTANKS AT SITE E.P.A. I.D.#(optional <br /> 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> F <br /> : NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST,FIRST PHONE p WITH AREA CODE <br /> TS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box toe 19 [�:j INDIVIDUAL O LOCAL-AGENCY STATE AGENCY.. <br /> CORPORATION I= PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE X WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ hoxtoX to E=I INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE X WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-]74- -FT—FT—=� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓Sm roXNicete 0 1 SELF-INSURED 0 2 GUARANTEE = 3 INSURANCE O 4 SURETY BOND I= 5 LETTEROFCREDIT 0 6 EXEMPTION O I STATE FUND <br /> � 8STATE FUND&CHIEF FINANCIAL OFFICER LETTER 1= 9STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O99 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.0 it.O III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> CQyNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE OPTIONAL CENSUS TRACT X -OPTIONAL 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 /> OWNER MUST FILE THIS FOR TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRC STORAGE TANK REGULATIONS <br /> FORM A(6-95) 1 I '�& <br />