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""Ou <br /> STATEOFCAUFORMA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �., a <br /> COMPLETE THIS FORM FOR EAC ACILITY)SITE <br /> MARK ONLY F7 1 NEW PERMIT 0 3 RENEWAL PERMIT IV <br /> 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED <br /> ONE REM 0 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA FACILI N NA OF OP R"OR A _ <br /> I <br /> Y Y <br /> ADD S /�� e n NEA TCROSSST ET PARCEL N(OFTIONAL) <br /> OLE `/'/L��t/- I <br /> CITY N E STATE ZIP C 2 in SITE PHOJ#WITH A EA COD <br /> CA f lJ/l <br /> ✓ BOX LOCAL-AGENCY <br /> TO INDICATE O CORPORATION 0 INDIVIDUAL =PARTNERSHIP DISTRICTS' 0 COUNTY-AGENCY' STATE-AGENCYFEDERAL-AGENCY' <br /> If owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR = ✓ IF INDIAN M OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 0 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#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> I. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> M CCARE OF ADDRESS INFORMATION <br /> 0 p <br /> btA ING DRES ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP (] COUNTY-AGENCY FEDERAL-AGENCY <br /> 6l`(NAME ST/�E� ZIP ODE� I /�i� PHONE#WITH AREA CODE <br /> / 1-06U C LJ' I <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> (]CORPORATION Q PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <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- - 0 1 Z <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COM LETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate 0 1 SELF-INSURED0 GUARANTEE i� 3 INSURANCE 0 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless ox I or II is checked. <br /> [CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. Il.F-1 III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ® FTFI PR 031117iae <br /> LOCATIO q,-OPTIONAL rENSUSf�'-QlpTlj�(t44L 3UPVISOR-DISTRICTDE - T70NAL <br /> ,31 132-1 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)ORMORE PERMIT APPLICATION- FORM B,UNLESS HIS IS A CHANGE OF SITE I ORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULA, <br /> FORM A(3193) FOR0033A-R7 <br /> 4r <br />