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0 <br /> STATE OF CAUFORWA A� ` <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MAR=ONLYE:] f NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CL <br /> ON2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSUfl <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAO CILITYNAME NAME OF OPERATOR <br /> O <br /> s <br /> ADDS_ I N RESTCROSSSTREET o PARCEL N(OPTIONAL) <br /> laJ� —':; <br /> CIN NAMEn G a, /.jr` STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> ✓ Box �/ <br /> TO INDICATE CORPORATION 11 INDIVIDUAL p(PARTNERSHIP LOCAL-AGENCY 0 COUMYAGENCV' STATE.AGENCY' FEOERALdGENCY' <br /> If inner of UST Is a public SI/\ DBTRICTS' <br /> p agency,complete the following:name GYPBNI6Ur of division.section,or office which operates the UST <br /> TYPE OF BUSINESS t GAS STATION ❑ 2 DISTRIBUTORa✓ IF INDIAN OF TANKS AT SITE E.P.A. I.D.a([phonal) <br /> Q 3 FARM 0 4 PROCESSOR 5 OTHER ❑ RESERVATION <br /> OR TRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) HONEi V4tTH AREA CODEDAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> a13 <br /> NIGHTS: NAME(LAST.FIRST) NE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) - PHONE s WITH AREA CODE <br /> ll. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxbindkale INDIVIDUAL D LOCAL AGENCY [::] STATE AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY.AGENCY 0 FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bot bIndicate E:1 INDIVB)UAL LOCAL-AGENCY <br /> D STATE AGENCY <br /> CITY NAME D CORPORATION I� PARTNERSHIP � COUNTY-AGENCY = FEDERAL-AGENCY <br /> STATE ZIP CODE PHO NEA WITHAREACODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if queslions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bIMkate 0 t SELF-INSURED <br /> F ❑2 GUARAMEE ❑ 3 INSURANCE <br /> D 5 LETTER OF CREDIT 6 EXEMPTION98 OTHER D 4 SURETY BOND <br /> Q <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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATN)NS AND BILLING: I.❑ II.❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF AfY KNOWLEDGE,IS TRUEAND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY D <br /> C�OOODUUNT'/�Y✓'7I/## JURISDICTION# 1` FACILRYx <br /> LOCATIONCODE -OPTIONAL CENSUS TpACT# -Q� NAL gUPVI5)fl-DISTR E •OPTIC <br /> ® <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM ff,-URrEffrHIS IS A CHANGE OF SITE INFORMATION ONLY, <br /> FORM#(353) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> kI (J�yyp/�[ <br /> FORMA-R7 <br /> / <br />