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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY L NEW PERMIT ) 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE 'I <br /> ONE ITEM Q 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACIUTY NAME NAM OF OPERATOR <br /> AD9RESS` NEAREST CROSS STREET PARCEL I(OPTIONAU <br /> (ly at/ JAM <br /> Crr <br /> CITY NAME STATE ZIP CODE SITE PHONE M WITH AR ODE <br /> ✓ Box ED CORPORATION LJ 1NOMWAL Q PARTNERSHIP Q LOCAL-AGENCY O COUNTY-AGENCYO STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDOATE DISTRICTS <br /> 'Noenerol USTiaapablia9e co mpletethelalbwng re ds4emiorofcf"pn,5edionaroXiwwhkhopoWeslhe UST <br /> TYPE OF BUSINESS 7 GAS STATION Q 2 DISTRIBUTOR Q ✓IF INDIAN p OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> 0 _S: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS V bo.to ncktlLOCAL-AGENCY -AGENCY N <br /> S CORPORATION PARTNERSHIP COUNTY-AGENCY Q FECERAL-AGENCY <br /> CITU NAME STa ZIP CO SE <br /> PWM <br /> HONE M Wl'AREA'O vol <br /> G.f( O(/L 3 <br /> III. TANK OWNER INFORMATION -(MUST BE COMPLETED) <br /> N OFOWN CARE OF ADDRESS INFORMATION <br /> {KTP <br /> MAILING OR STIR INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> (JD Jq� / <br /> O CORPORATION O PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> TVNAME �'� STA ZIP CODE � � PLR�W �ITH AREA DE _:3: <br /> eW:z <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F474- - <br /> � <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓hoa la inCraU I SELF INSURED Q 2 GUARANTEE O 31NSURANCE Q 4 SURETY BOND O 5 LETTEROFCREDIT O 8 EXEMPTION =T STATE FUND <br /> (] 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER Q 9 STATE RIND&CERTIFICATE OF DEPOSIT O io LOCAL GOVT.MECHANISM = 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] it,= It. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNA TANK OWNER'S TITLE DATE & MO/N�TWDAVIGYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION M FACILITY#119(, <br /> m 1,21'sl I N58 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL Ice <br /> THIS FORM MUST BE ACCOMPANIED BY AT-LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFOR ATION ONLY. <br /> OWNER MUST FILE THIS F099�THH THE LOCAL AGENCY IMPLEMENTING THE UNDERGR11j;S STORAGE TANK REGULATIONS <br /> FORM A(8-95) ve. <br />