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STATE OF CALIFORNIA .� <br /> STATE WATER RESOURCES CONTROL BOARD ; r <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 11 <br /> COMPLETE THIS FORM FOR EACH FA Y/SITE <br /> MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 PERMANEN SITE <br /> ONE ITEM F.7] 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARC <br /> CITY NAME _ �— STATE ZIP v/✓ / S17E PHONE s WITH AREA CODE <br /> ✓ Box - v1 Z <br /> TOfNDtCATE LJ CORPORATION '� INDIVIDUAL Q PARTNE P Cj DISTRICTS' <br /> Q COUNTY-AGENCY' Q STATE-AGENCY' [� FEDERAL-AGENCY' <br /> DSTRICTS' <br /> N 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 Is OF TANKS AT srr .E.P.A- I.D.s(gXiong <br /> RESERVATION <br /> Q 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonnl <br /> DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE's WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME i CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bo:q Md cats Q INDIytDUA1 Q LOCAL•AGENCY QSTATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q PMERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b frdtcats Q INDNIOUAt Q LOCAL-AGENCY Q STAT£-AGENCY <br /> _____ (]CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY Q F'EDEfiAI-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> 4 A--' <br /> TY(TK) HQ 741-4--l- ' <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS USED <br /> ✓ bot bindicate Q 1 SELF INSURED Q 2 GUARANTEE Q 3 INSURANCE <br /> 4 SURETY SONO <br /> Q 5 LETTEROFCREDIT 6 EXEMPTION Q gg 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 COXfPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED b SIGNED) OWNER'S TITLE DATE MONTH/DAYNEAR <br /> J <br /> LOCAL AGENCY USE ONLY <br /> COUNTY ar �/ /� JURISDICTION <br /> �_1 ! x FACILITY <br /> LOCATION E -OP710 AL CENSUS TRACT t RONAL SUPVISOR-DISTRICT CODE -OPTIONAL A�� <br /> Wn- <br /> THIS FOR` MUST BE ACCOMPANIED BY AT LEAST(l)6R MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF STTE IWORMAT ON ENLY, <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(3183) FOROR}]AR7 <br />