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�/ �°poo• a <o <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD s`y <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �e <br /> G� <br /> COMPLETE THIS FORM FOR EAC ACILITYISITE <br /> MARK ONLY O I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY QIQqPQ SITE <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT E S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBAPR FACILITY NAME OF OPERATOR <br /> /Q`VY � �`/ 1 � eI <br /> ADDRESS <br /> NEAREST CROSS STREET PARCEL*(OPTIONAL) <br /> 22f S- Cie/mo 6F <br /> CITY NAME STATEZIP CODE ITE PHONE#WITH AREA CODE <br /> GODT CA <br /> Ztl0 Zit)% -78'6 <br /> .1 BOX <br /> TO INDICATE O CORPORATION D INDIVIDUAL =PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY (] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESSI GAS STATION 0 2 DISTRIBUTOR O ✓ IF INDIAN #OF TAN AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM O 4 PROCESSOR O 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRS PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) �sr� /� 7 i 0 <br /> wa )OF <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PI4QNP a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Q `' <br /> MAILING OR STREADDRS <br /> O INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> . PARTNERSHIP COUNTY-AGENCY FEDEMLAGEN <br /> Y✓�ORPORAuON D <br /> CITY NAM STATE ZIP CODE P NE#WITH REA CODE <br /> 7 - )70Z--G°/// �5 D7 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> L o �koD vGT�i C!>th� `- <br /> MAILINGORSTREETADDRESS ✓�x (] INDIVIDUAL O LOCAL-AGENCY I� STATE AGENCY <br /> D, gQ CORPORA110N O PARTNERSHIP O COUNTY-AGENCY FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE WI H AREA E / <br /> v70Z-6�1/ 7/> ' 6 � <br /> IV.BOARD OF EOUA RzATI�OONjLISTT STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HO 4 4 - X� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ ba b NMkaN E:1 I SELF-INSURED 0 2 GUARANTEE E-1 3 INSURANCE 4 SURETY BOND <br /> 1 1 5 LETTER OF CREDIT O 6 EXEMPTION O W 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.O II- 111.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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY At <br /> Q d ( /a7eCu,�'Z7/ <br /> LOCATION CODE -OP�4 <br /> TIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DI ICT CODE -OP77ONAL 2 '� <br /> d Z - 0!�rl <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) FORW33A.5 / <br /> �� �7 <br />