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STATE OF CAUFORNMA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY Q 1 NEW PERMIT 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITEr <br /> ONE ITEM ❑ 2 INTERIM PERMIT 0 <br /> q AMENDED PERMIT 6 TEMPORARY SITE CLOSURE f <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAM / NAME OF OPERATOR <br /> ce y'1 L <br /> NEAR T CROSS STREET A PARCEL#(OPTIONAL) <br /> ADDRESS <br /> f (., <br /> STATE ZIP CODE SITE PHONE X WITH AREA LADE <br /> CITY NAME CA ;,f J <br /> ✓ 60X ]CORPORATSON INDIVIDUAL (� PARTNERSHIP Q LOCAUAGENCY l]COUNTY-AGENCY` ]STATE-AGENCY' ] FEDERAL•AGENCY' <br /> TO INDICATE DISTRICTS' <br /> "If owner of UST is a public agency,complHe the following:name of Superv'sor of division,sectbn,ar oNice which operates the UST- <br /> TYPE OF BUSINESS 1 GA5 STATION 2 DISTRIBUTOR ✓ IF INDIAN X OF TANKS AT SITE E.P.A. I.❑.X(opflonaf) <br /> D RESERVATION � <br /> 3 FARM � 4 PROCESSOR 0• 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 X WITH AREA CODE <br /> 700,, PHONE X WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE X WITH,AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> ^ f( <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> rw '., Cwt - <br /> MA1LlNG OR STREET ADDRESS /+ ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY [ STATE-AGENCY <br /> �,.f/ ]CORPORATION PARTNERSS{IP COUNTY-AGENCY FfDERALAGENCY <br /> c STATE 21P CODE PHONE X WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> LEISN <br /> -, CARE OF ADDRESS INFORMATION <br /> T ADDRESS ✓ tnx to indicate � {NDIVIOUAL � LOCAL-AGENCY � STATE-AGENCY <br /> Di]CORPORATION (] PARTNERSHIP 0 COUNTY-AGENCY ] FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> ©' �fv,o <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) Ma 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> 1 SELF-INSURED ]2 GUARANTEE l] 3 INSURANCE 4 SURETY BOND <br /> ✓ box iD Indicate [] 5 LETTEROFCREDIT 6 EXEMPTION Q 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 FOR LEGAL NOTIFICATIONS AND BILLING: I.O u.F—] III. <br /> THIS FOAM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED S SIGNED) OWNER'STITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION 0 FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)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 REGULATKINB FORD033A-R7 <br /> FORM A(3183) 0' 0 <br />