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u^ o� <br /> you. <br /> STATE OF CALIFORNIA � <br /> ��. <br /> STATE WATER RESOURCES CONTROL BOARD i��, v o <br /> �DERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a - <br /> �.x,.oa <br /> COMPLETE THIS FORM FOR EACH FAdLITYISITE <br /> MARK ONLY F7 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY C RE <br /> ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT 0 S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAMEOFOPERATOR <br /> ADDRESS INEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 300 s- C K Y r YP saaCITY NAME STATE ZIP CODE SITEPHONE#WITH AREA CODE <br /> Sin cic�vn CA 9'i 2.0 ? D %-Y <br /> I/ Box <br /> TO INDICATE CORPORA INDIVIDUAL PARTNERSHIPE--! LOCAL-AGENCY =1 MY TE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESSEA?�, GAS STATION Q 2 DISTRIBUTOR ✓ INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(aPH.W) <br /> R RVATION <br /> 0 3 FARM O 4 PROCESSOR Q 5 OTHER OR UST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON{SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) - PHONE#WITH AREA CODE DAYS: NAM AST,FIRST) - <br /> 114w <br /> P <br /> NIGHTS: NAME(LAST.FIRST) HONE#WITH AREA CODE NIGHTf_:_AME(LAST,FIRST) <br /> I PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME - CARE OF ADDRESS INFORMATION <br /> M l0" C I/ z- <br /> MAILING ORSTREET ADDRESS ✓bwbMW% INDIVIDUAL I� LOCAL.AGENCY STATE-AGENCY <br /> 3(0 S " -- O CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE, - ZIP CODE PHONE#WITH AREA CODE <br /> (� q'SZ o as V& - R�3 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box bindb INDIVIOUAL LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION 0 PARTNERSHIP E3 COUNTYAGENCY 0 FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) Ho 44 - 3 } <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> boo kk m O 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> 0 5 IETTEROFCREDIT =6 EXEMPTION O N OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is ch <br /> ycked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O 11. III.O <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 MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# S,t/10530 <br /> 11103 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> of ada 1 323 c x /// <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE 9f SITE INFORMATION ONLY. <br /> FORM A(5.91) /,/Z� FOR0033A5 <br />