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0 'QeOJR t9 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ,p o <br /> COMPLETE THIS FORM FOR EAC ACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACILTY NA E NAME FOPERATOR <br /> ADDRESS NEAREST CROSS STREET C PARCEL#(OPTIONAL) <br /> L(�i (sem Cly sail <br /> CITY NAM / STATE ZIP ODE SITE PHONE#WITH AREA CODE <br /> �toG PC •V�7�� CA <br /> 2�D ao <br /> ✓ BOz <br /> TO INDICATE D CORPORATION 1�INDIVIDUAL F-1PARTNERSHIP0 LOCAL-AGENCY <br /> OCAL- G NCV COUNTRAGENCV QSTATE-AGENCY FEDERAL-AGENCY <br /> DISTRI <br /> TYPE OF BUSINESS ❑ 1 GAS STATION 2 DISTRIBUTOR ❑ RESERVATS <br /> V IF DTION #OF TAV SITE E.P.A. I.D.A(optional) <br /> O 3 FARM O 4 PROCESSOR 5 OTHER I OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS. AME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PwnmP,WITH AREA CODE <br /> NIGHTS: E ILAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPER Y OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET A KESS ✓boa b Indicate E3 INDIVIDUAL [—I LOCAL AGENCY STATE-AGENCY <br /> I�CORPORATION I= PARTNERSHIP [1] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFOR TION.(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRESS ✓ box b Indicate L�l INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> I�CORPORATION [—j PARTNERSHIP = COUNTY-AGENCY ILj FEDEML#GENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST ST AGE FEE ACCOUNT NUMBER•Call(916)323-9555 it questions arise. <br /> TY(TK) HQ F4-T-41- D <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ boxbintlicala O 1 SELF-INSURED 2 GUARANTEE 0 7 SURANCE <SURETY BOND <br /> 5 LETEROFCREDIT 6 EXEMPTION 93 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. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAVNEAR <br /> LOCAL AGENCY USE ONLY aL a <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUSTRACTa3. -# T/ONAL SUPVISOR-DISTRICTCODE -OPTIONAL <br /> � •� <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 /> FORMA(5-91) J / j FORao9.iA:5 <br /> / � <br />