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STATE OF CALIFORNIA + <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> °400x N� <br /> COMPLETE THIS FORM FOR EAC ACILITYISITE <br /> 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY <br /> ONE ITEM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT � 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETIEDEOF OPERATOR <br /> DBA OR FACILITY NAME <br /> S NE REST CRO STREET DEL#(OPT <br /> IONAy <br /> ADD <br /> I fi� <br /> STATE ZIPCOD /� ' / ITE PHONE#WITH AREA CODE <br /> CITY NAME ^ <br /> TO BOX C-] <br /> 0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP Q LOCAbAGENCV 0 COUfM/V`#GENCV 1 STATE-AGENCY Q FEDEMLAGENCY <br /> DISTRICTS <br /> ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(ppd ae <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR RESERVATION <br /> a 3 FARM O 4 PROCESSOR 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> r u q�t8PHONF <br /> - <br /> NIGHTS: N M (LAST,FIRS PH WITH EACODE NIGHTS: NAME(LAST,FIRST) <br /> 11 <br /> II. PROPERTY OWNER INFORMATION- MUST COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME <br /> ✓ box WImicale INDIVIDUAL = LOCAL-AGENCY O STATE-AGENCY <br /> MAILING OR STREET ADDRESS <br /> CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY = FEDERAL AGENC <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) RE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> - - ✓ bindicab C� O <br /> INDIVIDUAL O LOCAL-AGENCY <br /> MAILING OR STREET ADDRESSSTATE-AGENCY <br /> Q COR ATION D PARTNERSHIP O COUNTY-AGENCY [�] FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - Q <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> 1 SELFINSURED 0 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> ✓ boa biibkala 5 LETTER OF CREgT 6 EXEMPTION 99 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 F00.LEGAL NOTIFICATIONS AND BILLING: )`''� <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) <br /> APPLICANTS TITLE DATE MONTHIDAVIVEAR <br /> LOCAL AGENCY USE ONLY G N, 5 / <br /> C�/ODU(NNTYYy��# JURISDICTION# FACILITY# <br /> L <br /> LOCATION ODE -OPTIONAL CENSUSTJAS# -OPTJQIVAL SUPVISOR-DISTRICT CODS OPTIONA <br /> 21_ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF S/7ryTE INFORMATION ONLY. s <br /> FORM A(5-91) 13 ® � L <br /> b • �� <br />