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t� U11 t <br /> Art .u.u, <br /> STATE OF CAUFORWA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> c <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A 3,, os <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITEF <br /> MARK ONLY � 1 NEW PERMIT � 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM a 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE GZ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE TE PHONE#WITH AREA CODE <br /> OD CA <br /> TOINDIC TE CORPORATION INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCYSTATE-AGENCY' FEDERAL-AGENCY' <br /> DISTRICTS' <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 �LGAS STATION 2 DISTRIBUTOR ✓ IF INDIAN OF TANKS AT I.D.N(optional) <br /> RESERVATION <br /> 0 3 FARM O 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DA ,.NAME(LAST, IRS T) PH NE*WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA COM 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 ✓ box IDindicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY [] FEDERAL-AGENCY <br /> CITYA E/ STATE _ ZIP CODE 0N ;Y;�;gODE <br /> III. TANK OWNER INFORMATIO -(MUST BE COMPLETED) <br /> vl� <br /> NAME OF OWNEH� CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 3 S% ORPORATION O PARTNERSHIP [] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY N ^ STATE ZIP �E_ � PHONE 4 WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)3222--9669 if questions arise.! 83 S <br /> TY(TK) HQ [4T4-]-j I H I _ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate I� 1 SELF INSURED 2 GUARANTEE 3 INSURANCE 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 box I or II is checked. <br /> [CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.E it.= 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 MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACIL"# _ <br /> S c U <br /> LOCATION CODE -OPTIONAL CENSUS TRA ;i #.OPTIONAL S VISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM 'THE LOCAL AGENCY IMPLEMENTING THE UNDERGROV TORAGE TANK REGULATM <br /> FORMA(3/93) �// � \ iy �/ FOR0033A{i7 <br /> D TJX Y <br />