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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "®� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT F'j 5 CHANGE OF INFORMATION [:] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O <br /> I. FACILrrY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA F CILITY NAME. NAME OF ERATOR <br /> e T r u G K S o c, t-�Pre <br /> igAD S q NEAR STREET PAIICELIIOPrIONAU <br /> CI NAM !V• STACA DIP S PH NE# ITH AREA CODE <br /> T IO NDICATE CORPORTICN Q INDIVIDUAL E-1 PARTNERSHIP O LOCAL-AGENCY 0 COUNTYAGENCY 0 STATE AGENCY E=j FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR RESERVATION <br /> O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. L D.#(optimal) <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAV : NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> n e q In i S PHONE A WITH AREA CODE <br /> NIGHTS: NAM (LAST.FIRSV PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boa 0lMkab [_1 INDIVIDUAL 0 LOCAL-AGENCY (] STATE-AGENCY <br /> I�CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OWNER CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING 3 STREET ADDRESS ✓box WwmaN O INDIVIDUAL O LOCAL-AGENCY STATE AGENCY <br /> CORPORATION (] PARTNERSHIP (]COUNTY-AGENCY FEDERLAGENCY <br /> CITY STATE ZIPHONE#WITH AREA CODE <br /> C P DE D <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916j323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bo,i blMkala 0 1 SELFINSURED Q 2 GUARANTEE O 3 INSURANCE E71 4 SURETY BOND <br /> = 5 LETtEROFCREDIT 0 6 EXEMPTION 99 OTHER <br /> 71 <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: L O 114 71 III- <br /> X <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPL ICANTS NAM E(PR INTED&S IGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# �FACILITY# <br /> LOCATIO OD -OPTIONAL CENSUSTRACT# -OPPQN4L SUPVISOR-DISTRICT CODE -OPTIONAL <br /> R -3 <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) 9 J��gi#'1 FORW33 <br /> 'lease i ssue <br />