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9 <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 ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE CJS <br />ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />NAME OF OPERA9TOR� <br />'r <br />`/!/0 <br />G AV�� <br />ADDRESS41/ <br />NEARESTO'ROSS REET <br />PARCEL#IOWpNAW <br />7 <br />) r <br />CITY NAME <br />STATE <br />ZIP CODE <br />9s36� <br />SITE PHONE # WITH AREA CODE <br />.' ®n <br />CA <br />CITY NAME /J <br />TOINOIICCATE D CORPORATION O INDIVIDUAL [__j PARTNERSHIP O LOCAL -AGENCY O COUNTY -AGENCY O STATE -AGENCY FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR <br />I ❑✓ IF INDIAN <br />RESERVATION <br /># OF TANKS AT SITE <br />I <br />E. P. A. I. D. # (optimal) <br />❑ 3 FARM ❑ 4 PROCESSOR Er 5 OTHER <br />OR TRUSTLANDS <br />` <br />�AREA <br />' z�/ <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NA E (LAST, FIRST)Py�ONE <br />vita c< <br />��% <br />#WITH AREA CODE <br />` 5 - 2 %Y <br />DAYS: NAME (LAST, FIRST) <br />NIGHTS: NAME (LAST, FIRST) <br />q vice/ cL <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE ; WITH AREA C011P <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />� <br />CARE OF ADDRESS INFORMATION <br />/f <br />q vice/ cL <br />CORPORATION D PARTNERSHIP COUNTY -AGENCY I= FEDERAL -AGENCY <br />MAILING OR STREET <br />✓ WX10Micale INDIVIDUAL <br />D LOCAL -AGENCY STATE -AGENCY <br />—ADyDRESS <br />I= CORPORATION = PARTNERSHIP <br />D COUNTYAGENCY FEDERAL -AGENCY <br />CITY NAME /J <br />STATE( <br />ZIP CODE <br />PHONE WITH CODE <br />O� <br />�AREA <br />' z�/ <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box b Indicate O INDIVIDUAL O LOCAL -AGENCY I] STATE -AGENCY <br />CORPORATION D PARTNERSHIP COUNTY -AGENCY I= FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />TY (TK) HQ 4 4- <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BECOMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box lo indicate F-1 I SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE [-14 SURETYBOND <br />O 5 LETTEROFCREDIT 0 6 EXEMPTION f%j-V 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. III. ❑ <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 MONTWDAWYEAR <br />LOCAL AGENCY USE ONLY <br />C�# JURISDICTION#�A1 FACILITY <br />LOCATION <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - <br />B. UNLESS THIS IS A CHANGF OF SRF INFORMATION ONI Y <br />r�nm q(o-yp C/\ORW333A 5 <br />