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STATE OF CALIFORNIA �.�• �, <br /> STATE WATER RESOURCES CONTROL BOARD V�� , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ;N _ , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE t <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAM NAME OF OPERATOR <br /> v T G v <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> N GIT. 3/' oz7. oyo-moi <br /> CITY NAME STATE ZIP CODE SITE PHONE R WITH AREA CODE <br /> Zbfl CA <br /> ✓BOX 0 CORPORATKIN 0 INDIVIDUAL 0 PARTNERSHIP E:j LOCAL-AGENCY 0 COUNTY-AGENCY' O STATE-AGENCY' O PEDERAL-MBICY' <br /> TO INDICATE DISTRICTS <br /> #owbrof UST b apu*agency.complete the folbetng:nameol supermorof 6+isim.sedbn oroNke aleck oPenetes the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR Q ✓IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.R(optional) <br /> ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUSTVATIO LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS NAME( ,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> per <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE R WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> XkC <br /> MAILING OR STREET ADDRESS ✓ bozbi7Wa OINDMIXNAL O LOCAL-AGENCY (] STATE-AGENCY <br /> a,- ce--FT Lz� 0 CORPORATION O PARTNERSHIP COUNTY-AGENCY FEJERAL-AGENCY <br /> CITY NAME STA ZIPCODE PHONE#WITH AREA CODE <br /> A 95�7/� oma, 333-/0 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF ER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESSI1 ✓ butoixcate 0 INDIVIDUAL 0 LOCAL-AGENCY O STATE,AGENCY <br /> CORPORATIONO PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE R ITH AREA CODE <br /> -:!),4 z z -•b <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 /> ✓boa bealwb D. 1 SELF-INSURED =2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND =5 LETTEROFCREDn O e EXEMPTION O T STATEFUND <br /> 0 B STATE RIND&CHIEF RNANCIAL OFFICER LETTER O 9 STATE FUND&CERTIFICATE OF DEPOSIT D 19 LOCAL GOVT.MECHANISM O 99 OTHER <br /> - <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.❑ I. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNERS NAME(PRINTED&SIGNATURE) TANK OWNERS TITLE DATE MONTHrDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 1 <br /> mGNaE2 Tv3 <br /> � <br /> LOCATION CODE -OPTIONAL CENSUS TRACT//N -��OP.��TIONAL 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 SITE INFORMATION ONLY. <br /> FORMA(6-95) <br /> OWNER MUST FILE THIS FOfi lTH THE LOCAL AGENCY IMPLEMENTING THE UNDERGR )STORAGE TANK REGULATIONS <br /> d ti <br />