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• � 'ayooA es <br /> STATE OF CALIFORNIA �O. <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�'� . vo <br /> r . o= <br /> COMPLETETHIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLYNEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM xa�.. ❑ ❑ OZ <br /> 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DDA CILITV NAMEn Y� Cl wz NAME FOPERATOR <br /> NEAREST CROGBOtREET PARCEL 0(OPTIONAL) <br /> CITY [f STATE ZIpjSITE PHONE#WITH AREA CODE <br /> CA C/1 G%//J/ri/f <br /> ✓ Box <br /> TO INDICATE CORPORATION 0 INDIVIDUAL D PARTNERSHIP O LOCAL-AGENCY COUMYAGENCY D STATE-AGENCY (] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O I GAS STATION ❑ 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANK AT SITE E.P.A. I.D.#(optimal) <br /> RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 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) PHONE 4 WITH ARPA C=5 <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRESS ✓ box b Indicate 0 INDIVIDUAL Q LOCAL-AGENCY O STATE-AGENCY <br /> (]CORPORATION O PARTNERSHIP D COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#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 blMicale Q INDIVIDUAL O LOCAL-AGENCY (] STATE-AGENCY <br /> CORPORATION O PARTNERSHIP ] COUNTY-AGENCY O FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 14 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECOMPL D)—IDENTIFY THEMETHOD(S) USED <br /> ✓ tax lo'mGicate E—� 1 SELF-INSURED E::]2 ARANTEE L:�] A INSURANCE L-1 1 SURETY BOND <br /> = 5 LETTER OF CREDIT EV6 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 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 /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY tt <br /> URISDICTION# FACILITY# <br /> //' K <br /> LOCATIC) OPTIONAL CENSUS TRACT# -OPT1y'LL SUPVg OE -OPTIONAL!f/TRICT C <br /> Z —� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OFSITE INFORMATION ONLY. ,>y / <br /> FORM A(12-e1) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS (yl`/'/ <br /> 0 <br /> Q FO11111,IR <br />