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um <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W�.,�� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A s <br /> o� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Oror<N,. <br /> MARK ONLYt NEW PERMIT 3 RENEWAL PERMIT 0 E::]5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM /t�2 INTERIM PERMIT AMENDED PERMIT [�j 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRUSS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> I;k e5 <br /> T� ) <br /> CITY NAME I t� V STATE ZIP DLA SITE PHONE#WITH AREA CODE <br /> CA <br /> �,( <br /> I/ BOX <br /> TO INDICATE <`IyJ CORPORATION Q INDIVIDUAL ED PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' 0 STATE-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 BUSINESSt GAS STATION Q 2 DISTRIBUTOR 0 RE/ IF INDIAN <br /> Is OF TANKS SITE E.P.A. 1.D.#(optional) <br /> ON <br /> 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE# TH AREA CODEJIGHtS: <br /> S: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> G NIGHTS: NAME(LAST,FIR PHONE# ITH AREA CODE,p NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> O <br /> II. P 'OPE <br /> NAMECARE OF ADDRESS INFORMATION <br /> MAI OR ST E DRESS L!� ✓box to Indicate INDIVIDUAL (� LOCAL-AGENCY (]STATE-AGENCY <br /> C_J C]CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITf NAME ZIP CODE PHONE#WITH AREA CODE <br /> 124537 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindicate INDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY <br /> lj CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME 1S7 7113 CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 44- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box ioindicate 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE 4 SURETY BOND <br /> D 5 LETTER OF CREDIT Q 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 II. Ill. <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 MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLYfac . Tb / <br /> COUrnNTY# JURISDICTION# FACILITY# <br /> a[ <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 SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3193) r 13_ !5 FOM&"7 / <br />