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'�aou• � <br /> c <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH-ii <br /> MARK ONLY r-1 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMA Y CLO ED SITE <br /> ONE ITEM O 2 INTERIM PERMIT F-1 4 AMENDED PERMIT E e TEMPORARY SITE CLOSURE Sa. <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME NAMED OPERATOR <br /> ADDRESS NEAREST CROSS STREET PAflCEIN(OPTIWIAU <br /> Y Ga <br /> CITY NAME STATE ZIP CODE SITE PHONE 4 WITH AREA CODE <br /> S v�v CA <br /> v BOX I F71 <br /> TOINDICATE O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 DISTRICTS LOCAL-AGENCY COUNTY-AGENCY O STATE-AGENCY [] FEDERAL-AGENCY <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR RESE11 <br /> RVNDDIAN 4 OF TANKS AT SITE E.P.A. I.D.4(cPdanal) <br /> ATION <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) #WITH AREA CODF <br /> ll. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME �.a✓ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bm bintlkm INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> Y (]CORPORATION (] PARTNERSHIP 0 COUNTY-AGENCY 0 FEDEMLAGENCY <br /> CITY NAME STATEZIP CODE PHONE#WITH AREA CODE <br /> s �ucv zv - rYy �c <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING Ofl STREET ADDRESS ✓box bbbkab 0 INDIVIDUAL D LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE <br /> IV, BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ F41 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bon binOkM 0 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> O 5 LETTER OF CREDIT O e EXEMPTION 0 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless Or It is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.Z II.O 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 NAM E(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# /LbZVJI-G0 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CGDE -OPTIONAL <br /> C7 z a to <br /> 3 Z cx� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATI ONLY. <br /> FORM A(5-91) 5 <br /> i <br /> ' i <br />