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F5��RCFS <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <��� 'gin <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1NEW PERMIT 3 RENEWAL PERMIT TION 7 PERMAN LY CLOS SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME �� NAME OF OPER�ITOR <br /> ADD F NEARESSSS3AEET PARCEL#(OPTIONAL) <br /> CISITE PHONE#WITH AREA CODE <br /> r K c a CA <br /> TO INDICATE CORPORATION ] INDIVIDUAL I] PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY E-1TAT <br /> SE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS l GAS STATION 2 DISTRIBUTOR / IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> O 3 FARM 4 PROCESSOR ] 5 OTHER OR TRUST LANDS SEVEW <br /> 6 , <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DA E L DA AME LAST FIRS <br /> NIG S PHONE#WITH AREA CODEHTS: NAME(LAST,FIf J\ ST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME , <br /> f� CARE OF ADDRESS INFORMATION <br /> MAILING OR ST ADDR SS ✓ box to indicate ] INDIVIDUAL [] LOCAL-AGENC ] STATE-A NCY <br /> `A )S Tg 6 �'v � �` CORPORATION � PARTNERSHIP [] COUNTY-AGENCY ] FEDERAL-AGENCY <br /> CITY NAME (J,+ / STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME pEAIN y ER f ` CARE OF ADDRESS INFOR TIONr, <br /> MAILING OR ET AD RESS ✓ box to indicate ] INDIVIDUAL <br /> LOCAL-AGENCY STATE-AGENC <br /> —(� �� CORPORATION (] PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY N A 1, STA ZIP CODE v PHONE#WITH AREA CODE <br /> Y' - %- c 3V,_K' I� <br /> IV. BOARIAF EQUALIZATION U STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4441-t- c <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate I SELF-INSURED ]2 GUARANTEE 3 INSURANCE ]4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION E_] 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.[ �] II.D III <br /> THIS FORM HAS BEEN OMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED& EI APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LO AL AGENCY SE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> :3, <br /> q 3ILlI s d s' al r <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 SI ON ONLY. <br /> TOPM A(12 91) FILE THIS FORM WITH&OCAL AGENCY IMPLEMENTING THE UNDERGROUND SOGE TANK REGULATIONS <br /> FOR0033A-R6 <br />