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SoURGFS <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTRO^$RIYF�#oUNDERGROUND STORAGE TANK PERMIT <br />o <br />S Cn�iFon N� <br />COMPLETE THIS FORM FOR EACH FACILrnY/H 16 19q <br />MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE <br />'t�OtF� INFORMATION � 7 PERMANENTLY CLOSED SITE <br />ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT L_] 6 TBAIFQOHw�7iN"EMAyPf4GAITLt <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />NAME OF OPERATOR _ <br />ADDRESS <br />NEAREST CROSS STREET PARCEL # (OPTIONAL) <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />Tf a c <br />CA <br />- a3 -V <br />& <br />--- ✓ Box <br />TO INDICATE CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL -AGENCY COUNTY -AGENCY (_J STATE -AGENCY FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR✓ <br />IF <br />IF INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />0 3 FARM 4 PROCESSOR = 5 OTHER <br />OR TRUST LANDS <br />c <br />vs <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST. IRST) _ <br />PHONE # WITH AREA CODE �7 <br />DAYS: NAME (LAST, FIRST) - �S <br />MAILING ORJJTjD R SS <br />rt�9"3'.)3--%dis <br />&ti,vx�ta nF <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRS _ S�6 �� I <br />v- a <br />- a3 -V <br />& <br />II- PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />x � <br />I—`�t ti_'}l <br />CARE OF ADDRESS INFORMATION <br />CARE OF ADDRESS INFORMATION <br />MAILING ORJJTjD R SS <br />MAILING OR STREET ADDRESS <br />LOCAL -AGENCY STATE -AGENCY <br />COUNTY -AGENCY FEDERAL -AGENCY <br />✓ box toindicate ® INDIVIDUAL <br />LOCAL -AGENCY STATE -AGENCY <br />Q <br />y <br />CORPORATION 0 PARTNERSHIP <br />0 COUNTY -AGENCY FEDERAL -AGENCY <br />CI�b1E <br />STATE <br />ZIP ODE <br />PHONE # WITH AREA CO E <br />c <br />vs <br />- 5 <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />N --ER <br />NAME OF OOW//S� <br />CARE OF ADDRESS INFORMATION <br />MAILING ORJJTjD R SS <br />box to indicate INDIVIDUAL <br />CORPORATION PARTNERSHIP <br />LOCAL -AGENCY STATE -AGENCY <br />COUNTY -AGENCY 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 14-14 1- II— LL I I <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED <br />✓ box to indicate 1 SELF-INSURED E:1 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br />CI 5 LETTEROFCREDIT E::] 6 EXEMPTION 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: L F-] II. ❑ III. <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANT'S NAME (PRINTED & SIGNATURE) APPLICANT'S TITLE DATE MONTH/DAY/YEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # FACILITY # <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 SITE INFORMATION ONLY. <br />FORM A (12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />�� FOR0033A-R6 <br />