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• `bWe C9 C <br /> STATE OF CALIFORNIA <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> y <br /> 0 <br /> COMPLETE THIS FORM FOR EACH F YIstm `'tura <br /> MARK ONLY F-1 1 NEW PERMIT O 3 RENEWAL PERMIT EV5 CHANGE OF INFORMATION O 7 PERMA -� D SITE <br /> ONE ITEM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 81 ADDRESS-(MUST BE COMPLETED) <br /> ORA OR FACILITY NPME r NAMEOFOPERATOR <br /> VI 5 <br /> ADDRESS r Q EAflEST CROJREET ',,n PARCEL OPFgNAL) <br /> 16 1157 M <br /> CITY NAME STATE DE / SITE PHONE a WITH AREA CODE <br /> CA <br /> TO Box INDIVIDUAL CORPORATION 0 INDIVIDUAL l�PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> 'If owner of UST Is a public agency,complete the fallowing:name of Supervisor of division,section,or office,which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR RESERVATION <br /> a OF TANKS AT SITE E.P.A. 1.D.a(aprMwl) <br /> O 3 FARM Q 4 PROCESSOR Q e OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST, S PHONE a WITH AREA CODE NIGHTS: NAME(L 1,1-IK5T) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bot bintlkals Q INDIVIDUAL O LOCAL-AGENCY Il STATE AGENCY <br /> (]CORPORATION 0 PARTNERSHIP E-1 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ butbinEbaN Q INDIVIDUAL O LOCAL-AGENCY O STATE AGENCY <br /> Q CORPORATION D PARTNERSHIP COUNTY-AGENCY Q FEDERALAGENCY <br /> CITY NAME V - STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGEFEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-T4-1- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box binsbale = 1 SELF-INSURED =2 GUARANTEE 0 3 INSURANCE Q 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT O 6 EXEMPTION O 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: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KN LEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED 6 SIGNED) OWNEWS TITLE DATE MONTWJDAY/Y R <br /> LOCAL AGENCY USE ONLY (�f <br /> COUNTY# <br /> 7v�(T JURISN• FACILITY <br /> 11 1 <br /> LOCATION CODE -OPTIONAL CENSUSTRACTa - TIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLE$,S THIS IS A CHANGE OF siREE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU,,N,D'%TCRAGE T7*71EG TIT <br /> FORM A(393) _T/J—/)�(J CIO l/ Farom3A.R7 <br /> i <br />