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411 e V� <br /> STATE OF CAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACHFACILITYISITE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED& E <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ITY AME DR NAME ERATOR <br /> bmw <br /> ADNEAR TCROSS Am STH f.H'//v PARCEL#(OPTIONAL) <br /> CITY NA STATEZIP/ . SITE PHONE#WITH AREA CODE <br /> CA <br /> T INDICATE0 CORPORATION INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY <br /> COUNTY-AGENCY' STATE-AGENCY' ED FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner d UST Ie a public agency,complete the following:name of Supervisor of division,section,or office which cpermse the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR RESERVATION <br /> INDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.#(cplbnal) <br /> ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS J 09 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS _ ✓wa bl�� D INDIVIDUAL I� LOCAL-AGENCY 0 STATE-AGENCY <br /> D CORPORATION = PARTNERSHIP D COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAM 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 ✓ boa b ln#bue INDIVIDUAL Q LOCAL-AGENCY [] STATE-AGENCY <br /> CORPORATION PARTNERSHIP D COUNTY AGENCY 0 FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPO D)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa lo Indicate O 1 SELF-INSURED 1::12 PMANTEE 0 3 INSURANCE [-14 SURETY BOND <br /> =5 LETTER OF CREDIT EXEMPTION O aI 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.❑ IL❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF ANY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# 'PINCIEv* /� � <br /> 37 jizili <br /> LOCATION COnOPT/ONAL CENSUS TRACT# -OP O SUPVISOR-DISTRICT 90DE •OP7pNAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMITAPPLICATION- FORM B,UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY. V <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) FOR0033Ag7 <br /> 39a ,"P is <br />