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... t tbOun Qy <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W 4a a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F—] t NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE <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 OR FACILITY NAME NAME OF OPERATOR <br /> A E , NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME � ( V 7V STATE CEZIP p _ � SITE PHONE k WITH AREA <br /> A CODE <br /> TOINDICATE I]CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q 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 O t GAS STATION 0 2 DISTRIBUTOR ✓RESERIF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> VATION <br /> l) 3 FARM 4 PROCESSOR l) 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) PRIONE4 WITH AREA CON NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> tf < < <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME q CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box b Indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> i Q Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NA 41 STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR,STR ET ADDRESS ✓box b indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> fT <br /> TK) H <br /> F EQUALIZATION UST ORA FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> 4 4- - <br /> / 4 11 7K I, 4< <br /> V. PETRO IBILITY- I ST B t�=IDENTIFY THE METHOD <br /> (S) USED <br /> ✓IxzbMdM Q iSELF-INSUREDG l)3 INSURANCE l)4 SURETY BOND <br /> 5 LETTER OF CREDIT Q 6 EXEMPTION Q 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: 1.ED 11.0 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 MONTWDAY/YFJ►R <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> L4 I I 1 —1 1 ..? <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)0 MORE PERMIT APPLICATION. FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS. <br /> FORMA(3/93) F080003A-R7 <br /> 7 41? <br />