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0 a <br /> STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM ACOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE_ ,✓ <br /> ONE ITEM ❑ 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) / <br /> DBA OR FACILITY AME NAMEOFOPERATOR <br /> ADDRESS�/ (j NEARESTCROSS STREET PARCEL#IOPTIONAU <br /> CITY NAME STATE ZIP CODE SITE PHONE N WITH AREA CODE <br /> ? 7 CA Z -7 <br /> TOO INgoxTE D CORPORATION INDIVIDUAL PARTNERSHIP D LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner G UST is a public agency,complete the following:name of Supervisor of d"lon,section.or chips which operates the UST <br /> TYPE OF BUSINESS-- i GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN N OF TANKS AT SITE E.P.A. I.D.#(golionall <br /> ESERVATION <br /> ="3 FARM ❑ A PROCESSOR 6 OTHER OgTRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: <br /> -�NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> '�P <br /> NIGHTS: NAME(LAST,ST,FIRST) PHONE#WITH AREA DE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILINN9,RR STREET ADDRES�Sj ✓ boxbbbkaY INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> C//. / d. F—)CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STA 21P CODE PHONE N WITH AREA CODE <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER _ CARE OF ADDRESS INFORMATION <br /> J/tG/ .' CG-� - <br /> MAILIISTREET ADDRESS <br /> ✓ borbiMicate 0 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> C G - CORPORATION O PARTNERSHIP D COUNTY-AGENCY Q FEDEPAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#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 /> ✓bot bindicate t SELF-INSURED 2 GUARANTEE 0 3 INSURANCE L-1 N SURETY BOND <br /> 5 LETrER OF CREDIT 6 EXEMPTION O gP OTHER <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: 1.0 11.0 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(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION If FACILITY• <br /> m Ma I <br /> LOCATION CODE -OPTIONAL CENSUSTRACT#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 FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3'83) • FOi60T3AA7 <br /> 0 <br />