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� 0 nct9 <br /> STATE OF CALIFORNIA c4`± <br /> STATE WATER RESOURCES CONTROL BOARD ^4F <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A °F �, _� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY �Q T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED.SITE <br /> ONE ITEM F-1 2 INTERIM PERMIT <br /> 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAME OF OPERATOR���a <br /> DBA OR FACILITY NAME .,-,,.�f! NEAREST CROSS ET PARCEL X(OPTIONAL) <br /> ADDRESS <br /> � ..a f/�`�(//A77 <br /> /11 Ril f <br /> CITY NAME STATE LP CODE SITE PHONEp WITH AREA CODE <br /> CA Z up GADO <br /> ✓BOX O CORPORATIONINDIVIDUAL r__I PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCYFEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 11 ower of UST isa public agen f.mmple,the lullowing:name of supervisor M Mh op <br /> dwmion,Wien or office erates the UST ✓IFINDIAN XOFTANKSATSITE E.P.A. I.D.#(optional) <br /> TYPE OF BUSINESS O t GAS STATION O 2 DISTRIBUTOR [�:] RESERVATION ^^�� <br /> 3 FARM Q 4 PROCESSOR V 5 OTHER OR TRUST LANDS V°-,. C-��10 0 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> PHONE X WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> DAYS: NAME(LAST.FIRS TL ^� <br /> NIGHT NAME(LAST,FIRST) <br /> PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> r <br /> II. PROPERTY OWNER INFORMATION-(MUST BE 0Olk1PLFTFD) <br /> CARE OF ADDRESS INFORMATION <br /> NAMEWKRESS9 <br /> ✓ bca to hCc��` �V4'OIVIOUAL OLOCAL-AGENCY I� STATE-AGENCY <br /> MAILING OR S41, <br /> / O CORPORATION =PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAMF�.. �,4- STA ZIP CODE PHONE X WITH AREA CODE <br /> 5 �,¢ 2 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME OF OWNE <br /> � L /S <br /> MAILING OR STREET ADDRESS ✓ boa to ntlirala -[�JNOIVIDUAL QLOCAL-AGENCY <br /> l�$TATE-AGENCY <br /> ES/F L O CORPORATION O PARTNERSHIP Q COUIM-AGENCY Q FEDERAL-AGENCY <br /> w/�.� /,,/ / $T/!�T ZIP CODE PHONEp WITH ARfE�AC DE (, <br /> CITY NAME /BOG/`• /(j� 6. �/ L GX % a Z. J:7�J <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 it questions arise. <br /> TY(TK) HQ 4 F4-1- <br /> V. <br /> - -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to Wicale •jjl�t SELF-INSURED O 2 GUARANTEE C3 3 INSURANCE 4 SURETY BOND 0 5 LETTEROFCREDIT O 6 EXEMPTION 0 L STATE FUND II <br /> 08 STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT OIoLOCALGOVT.MECHANISM 1� 99 OTHER �•� �— <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. <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 TITLE DATE MONTWDAYNEAR <br /> TANK OWNER'S NAME(PRINTED&�S/I/G'N/ATUREC) f/ <br /> LOCAL AGENCY USE ONLY t <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACTX -OPTIONAL SUPVISOR-DISTRICT C09E -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 THE LOCAL AGENCY IMPLEMENTING THE UNDERGROJSTORAGE TANK REGULATIONS <br /> FORMA(6-95) <br />