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0 0 P�,OUNC S C <br /> STATE OF CALIFORNIA AP o <br /> 1 <br /> STATE WATER RESOURCES CONTROL BOARD W dam, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A00 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE t� <br /> • C�—IOM N,� <br /> MARK ONLY1 NEW PERMIT F-1 3 RENEWAL PERMIT F7 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE .SITE <br /> ONE ITEM a 2 INTERIM PERMIT Q 4 AMENDED PERMIT [�:] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> S c-• <br /> DDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 1p �" C 4 �'Cr-i <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> ✓BOX CORPORATION INDIVIDUAL (� PARTNERSHIP Q LOCAL•AGENCY O COUNTY•AGENCY' (� STATE-AGENCY' OFEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> '#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 a 2 DISTRIBUTOR ✓IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: (LAST,FI ST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> WM <br /> NIGHTS: N E(LAT 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 /> { <br /> MAILING OR STREET ADDRE ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> SI S (fie CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAM STATE ZIP CODE PHONE#WITH AREA CODE <br /> S G on <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNF,R CARE OF ADDRESS INFORMATION <br /> q44 <br /> MAILING OR STREET ADD SS ✓ boxto indicate INDIVIDUAL D LOCAL-AGENCY 0 STATE-AGENCY <br /> Q- S Cla e� r X CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY nc�±66 <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> L" 6 —4 - �Q� <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 COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED O 2 GUARANTEE =3 INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT O 6 EXEMPTION =7 STATE FUND <br /> 6 STATE FUND&CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM O 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.= It.0 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTH>DAYNEAR <br /> y k <br /> J �rI <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-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 SIT't-KFORMATIOd ONLY. <br /> FORMA(6-95) OWNER MUST FILE THIS FORPO THE LOCAL AGENCY IMPLEMENTING THE UNDERGROOTORAGE TANK REGULATIONS <br />