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I <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY 1 NEW PERMIT F—] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [�] 7 P ENTLY CLOSED SITE <br />ONE ITEM F-12 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ;0 <br />ONE <br />I. FACILITY) INFO TION & AD ESS - ST BE COMPLETED) <br />DBA 011,FAC <br />NAME r <br />! <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NAME OF OPERATOR <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />ADD SS <br />NEAREST CROSS STREET <br />PARCEL # OPTIONAL) <br />I <br />Cl <br />NAME <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />S -1v <br />CA <br />✓ BOX <br />NDICATE <br />CORPORATION <br />INDIVID PARTNERSHIP <br />0 LOCAL -AGENCY 0 COUNTY -AGENCY <br />0 STATE -AGENCY FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUS <br />ON = 2 DISTRIBUTOR <br />0 ✓ IF INDIAN <br /># OF TANKS AT <br />SITE <br />E. P. A. I. D. # (optional) <br />RESERVATION <br />3 FARM <br />4 PROCESSOR O <br />5 OTHER <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />I t A u V <br />DAYS: NAME (LAST, FIRST) <br />NIGHTS: NAME (LAST, FI ST) PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />II- PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box tD Indicate E:] INDIVIDUAL E�] LOCAL -AGENCY El STATE -AGENCY <br />CORPORATION [_1 PARTNERSHIP COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to indicate E::] INDIVIDUAL (] LOCAL -AGENCY STATE -AGENCY <br />E=1 CORPORATION = PARTNERSHIP Q COUNTY -AGENCY E�j FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />IV. BOARD OF AION STORAGE FEE ACINT NUMBER •Call (916) 323-9555 if questions arise. <br />TY (TK) H 4 - V 1 DL I Llto <br />V. PETR LEUM UST FINANCIAL RESPONSIBILITY - (MU BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to indicate 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br />FD 5 LETTEROFCRE = 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. D 11. 1-1 M. <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANTS NAME (PRINTED & SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # FACILITY # f9/V�P�, <br />MI Fm 1_1111viki <br />LOCATION CODE - OPTIONAL CENSUS TRACT # -OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL <br />o / �1 3,2--3 <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 />FORM A(5-91) �, t ,� �• — r 1 FOR0033A-5 <br />l* 03dS HiIV31 i i�ilv3 NI'u OUIIM��133113iSl. h 80IN3S <br />0 <br />hk <br />