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�4 YIR� C <br /> STATE OF CALIFORNIA Fir <br /> STATE WATER RESOURCES CONTROL BOARD Y � i a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT X5 CHANGE OF INFORMATION 7 PERMANENTLY <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ B TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFOR TON&APDRES-(MUST B C MPLETED) <br /> DBA OR FACILITY NAME / NAME OF OPERATOR <br /> C <br /> ADDF1 n \ NEAREST CROSS STREET PARCEL#(OFOONAL) <br /> CITY NAMFrr © ! S7 TE ZIP CODE SITE PHONE WITH AREA CODE <br /> CA <br /> BOX <br /> T NDICATE CORPORATION 0 INDIVIDUAL Q PARTNERSAP Q LOCAL-AGENCY COUNTY-AGENCY' [] STATE-AGENCY' E�] FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner of UST Is a Public agency,complete the following:name of Supervisor of d"lon,section,or office which operates the UST <br /> TYPE OF BUSINESS1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OFT AT E.P.A. I-D.#(optional) <br /> RESERVATION AOL I <br /> 0 FARM 4 PROCESSOR = 5 OTHER OR TRUST t-ANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CO CT PERSON (SECONDARY)-optional <br /> DAYS: NAME AST,FIRST) _ PHgO�NE#WI7H AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 1-^ � �f C i � �l�' <br /> NIGHTS: NAME(LAST,FIRS PHQ�E WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- 11MUST BE COMPLETED <br /> NAME I <br /> OS CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET AODR SS ✓ box h Indicate 0 INDIVIDUAL <br /> LGA CI TON OLOCAL-AGENCY STATE-AGENCY <br /> CORPORAPARTNERSHIP <br /> COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME r- t STATE ZIP CODE <br /> DEPHONE 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 ✓ box 10inditate [] INDIVIDUAL 0 LOCAL-AGENCY S7ATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 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 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> J box to indicate E71 I SELF-INSURED [::] 2 GUARANTEE [] 7 INSURANCE <br /> 0 4 SURETY BOND <br /> E-D 5 LETTER OF CREDIT F-1 6 EXEMPTION 0 99 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.[-] II.D III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BUST CE MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTH/OAYMEAR <br /> LOCAL AGENCY USE ONLY -�,L, �P C' <br /> COUNTY# JURISDICTION# FACILITY <br /> LOCATION CODE -OPTIONAL CENSUS TRACT OPT! PE L SUPVISOR-DISTRICT CO -OP770ML <br /> CvJC��-yL��8 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FOAM A(3+93) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR9E,03Aa17 <br />