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STATE OF CALIFORNIA ,! moi. <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w�`� " �e <br /> Y . <br /> O„M,� <br /> COMPLETETHIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY O I NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATON O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM D 2 INTERIM PERMIT D 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME NAME'V <br /> OPERAT R <br /> l e5wV <br /> ADDRESS NEARE TGROSS STREET PARCEL*(OPTIONAL) <br /> v 5; - r L Or F <br /> CITY KIME STATE ZIP DE TE PHO E#WITHEA CODE <br /> CA �1va►� �r 066,0 <br /> BOX TOINgOATE D CORPORATION INDIVIDUAL I�PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY I� FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR / IF INDIAN RESERVATION #OF TANKS AT SITE E.F A. I.D.#(optional) <br /> Q 3 FARM O 4 PROCESSOR OTHER OR TRUST LANDS 1 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAXS NAME(UST,FIRST) P E#WI H AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE s WITH AREA Onn:JNIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COD <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAM CARE OF ADDRESS INFORMATION <br /> dim <br /> MAILING OR STREET ADDRESS ✓ bUbintlkme (] INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> Q. Q (]CORPORATION PARTNERSHIP (] COUNTYAGENCY FEDEML-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> r-A&forsr c� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM1 E OF OWNER CARE OF ADDRESS INFORMATION <br /> Fs'fYl- <br /> MAILINGORSTREETADD ESS ✓boa0 wicam O INDIVIDUAL LOCAL-AGENCY (]STATE-AGENCY <br /> 05I <br /> 0- Z -7 CORPORATON ARTNERSHIP OCOUNTY-AGENCY FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> G <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bm biMkab 0 I SELF INSURED (]2 GUARANTEE 3 INSURANCE O 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT I�9 EXEMPTION 99 OTHER <br /> 771 <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.❑ it.O 111.1:71 <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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> Z0151 c��F 6 2 <br /> LOCATIOO CODE -OPTIONAL CENSU TRACI# -OP77ONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> CA / <br /> C-- 7- so g/ Z g 10/C& <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(5-91) I���� /FOg00.77A5 �y <br />