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0 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARDc <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> •C�(IfON N.r <br /> COMPLETE THIS FORM FOR EAC ACILrrYISITE <br /> MARK ONLY 0 1 NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM a 2 INTERIM PERMIT 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMENAME OF OPERATOR <br /> G D <br /> ADDRESS NEAR ST CROSS STREET PARCEL#(OPTIONAL) <br /> AAA <br /> CITY NA STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> BOX <br /> TO INDICATE CORPORATION 0 INDIVIDUAL = PARTNERSHIP 0 DS RIC SENCY 0 COUNTY-AGENCY (] STATE-AGENCY Q FEDERAL-AGENCY <br /> TYPE OF BUSINESS = 1 GAS STATION 2 DISTRIBUTOR / ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 1�)�// 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) <br /> NI TS: N M (LASTd`1STj #vvrrH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE;#WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME �'I ww ' CARE OF ADDRESS INFORMATION <br /> MAILIN�R STET ADDR (�/IIJ� ✓ IDiMlcate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> i CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CE <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> Q CORPORATION 0 PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate O 1 SELF-INSURED 2 GUARANTEE �= 3 1 URANCE 4 SURETY BOND <br /> 5 LETTEROFCREDIT 6 EXEMPTION L^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.= II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION C©;OPTIONAL CENSUS TRS T# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,,UNLESSTHISIS A CHANGE OF SRE PIFORMATION ONLY. <br /> FORM A(5-91) FOROM3A-5 <br />