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STATE OF CAUFORMA `• '� ,fi �'1 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITIffSTTE <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERM17 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM ;J 2 INTERIM PERMIT 71 A AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE 3 <br /> 1. FACILITYISITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> co 14k <br /> ADDRESS NEAREST CROSS STREET FARCEI*(CPIIONAU <br /> C✓c- Tom•--� <br /> CITY NAME STATE ZIP CODE SITE PHONE*WITH AREA CODE <br /> S'40C A" + - � CA 9sao� Zv - Y3—/ � <br /> roW BOX <br /> O C��'TKN O�VWAL O PARTNERSHIP �NAGENCY O COUMYAGENCY �STATE-AGENCY FEDEIMLAMNCY <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN *OF TANKS AT SITE E.P.A. L 0.r(apLiR00 <br /> Q Q RESERVATION <br /> G 3 FARM O A PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> QC(µ n guy - 9 -r <br /> NIGHTS: NAME(LAST. ST) PHONEFIONE* NKiHTS: NAME(LAST,FIRST) <br /> PHONE 0 WTW ARE6 <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME // CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ wbb [=INDNDIIAL LOCAL-AGENCY (]STATE-AGENCY <br /> O CORPWIATION EJ PARTNERs19P O CWNtyAuNcY p FEDERAL-AGENCY <br /> CITY NAME STATE Zip CODE PHONE*WITH AREA CODE <br /> S40rkAV--\ I C�9 9SZOO p - 4y3YyJ / <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ mI b mar (]WIVOUAL Q LOCALAGENCY O STATEAGEMCY <br /> p CORPORATION (_l PARTNERSHIP p COUNN-AGENCY O FEDERMAGFICY <br /> CITY NAME I STATE I ZIP CODE PHONE A WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 0 questions arise. <br /> TY(TK) HQ 744 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ Ou bn2Kar J 1 SELF-INSURED V 2 GUARANTEE u 3 INSURANCE U•SUflETY BOND <br /> (]5 LETTER OF CREDO =6 EXEMPTION C 96 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is check . <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. it. 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 B SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY s JURISDICTION a FACILITY a RF,vr4 /S <br /> LOCATION CODE -OPTIONAL (CENSUS TRACT -OPTIONAL ISUPVISOR-DISTRICT CODE -OPTIONAL <br /> o / cz 3a 3 /rl/�/s <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(S91) FOROM A5 <br />