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• <br />• <br />STATE OF CAUFORMA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EACH <br />MARK ONLY 1 NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CIL�� I <br />ONE REM 2 INTERIM PERMIT 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br />I FAINI rTVICITF INFnAUATmN i AnnRFSS - (MUST RE COMPLETED) <br />DBA OR FACILITY NAME <br />DAYS: NAME (LAS .FIRST) PHONE s WITH AREA CODE <br />NAME OF OPERATOR <br />-_ <br />WITH AREA <br />TSAME (LAST, F EA <br />LAST. <br />TSNAME'( n PHONE s NTH AREA CODENI <br />oCODE <br />1�NI <br />MAILING15R STREET ADDRESS <br />✓ box Io indicate C:1 INDIVIDUAL <br />0 LOCAL -AGENCY <br />C STATE -AGENCY <br />Q CORPORATION (] PARTN <br />A ORES <br />FEDERAL -AGENCY <br />CITY NAME n <br />NEARES R STR <br />PARCELN(OPIYONAy <br />/ <br />cev <br />i CODE f / <br />A/ U <br />CITY NAME <br />STATE <br />ZIP E <br />SITE PHO s WITH AREA CODE <br />CA <br />T NDICATE <br />CORPORATION IVI PARTNERSHIP <br />(] LOCAL -AGENCY 0 COUNTY-AGENCY <br />F STATE -AGENCY- Q FEDERAL -AGENCY' <br />DISTRICTS' <br />H 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 <br />2 A STATION Q 2 DISTRIBUTORQ <br />%/ IF INDIAN <br />s OF TANKS AT SITE <br />E. P. A. 1.0. s (optional) <br />0 3 FARM Q 4 PROCESSOR Q 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRS PHONE s WITH AREAC,,ODE <br />DAYS: NAME (LAS .FIRST) PHONE s WITH AREA CODE <br />f -A2 - ,rz Z <br />WITH AREA <br />TSAME (LAST, F EA <br />LAST. <br />TSNAME'( n PHONE s NTH AREA CODENI <br />oCODE <br />1�NI <br />A II. PROPERTY OWNER INFORMATION <br />- (MUST BE COMPLETED J <br />OWNAME <br />G OR TREET D ESS <br />�- <br />CI I NAME <br />TANK OWNER INFORMATION - (MUST BE <br />ADDRESS INFORMATION <br />✓ box 10 Indicate (] INDIVIDUAL 71 LOCAL -AGENCY Q STATE -AGENCY <br />CD CORPORATION PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />ST XKS ZIP CODE I PHO E/s WITH AREA CODE <br />NE OF OWNER <br />CARE OF ADDRESS INFORMATION <br />E <br />MAILING15R STREET ADDRESS <br />✓ box Io indicate C:1 INDIVIDUAL <br />0 LOCAL -AGENCY <br />C STATE -AGENCY <br />Q CORPORATION (] PARTN <br />COUNTY -AGENCY <br />FEDERAL -AGENCY <br />CITY NAME n <br />STATE <br />21P C� �� <br />Ptd i WI <br />i CODE f / <br />e <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 io indkate O 1 SELFINSURED a 2 GUARANTEE (] 3 INSURANCE (] 4 SURETY BOND <br />O 5 LETTER OF CREDIT 6 EXEMPTION (] s9 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 />ICHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L Z 11. F-1 Ill. I <br />T141S 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 MONTHIDAYlYEAR <br />LOCAL AGENCY USE ONLY FID 00 OJ7 ff Pit <br />COUNTY* JURISDICTION FACILITY 2`- ( <br />LOCATION CODE - OP77ONAL CENSUS TRACT if - OP77ONAL SUPVLSOR- DISTRICT CODE - CIPTMAL <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION -FORM B, UNLESS ms IS A CHANGE OF SITE INFORMATION :2F`1_ <br />OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNOERGR STORAGE TANK REGULATIONS <br />