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STATEOFCAUFORNA <br /> STATE WATER RESOURCES CONTROL BOARD c <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A o <br /> ryi <br /> COMPLETE THIS FORM FOR EACH FAgLRYISITE <br /> MARK ONLY ❑ I NEW PERMIT J. 3 RENEWAL PERMIT J 5 CHANGE OF INFORMATION O Z PERMANENTLY CLOSED SITE <br /> ONE REM U 2 INTERIM PERMIT i_j A AMENDED PERMIT '� 6 TEMPORARY SITE CLOSURE ' <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) S) <br /> DAOR FACILITY NAME NAMEOFOPERATOR <br /> ADDRESS NEAREST CROSS STREET PACELJ(OOPpNAI <br /> CITY NAME p <br /> co- <br /> STATE ZIP CODE 3 A WITH AREA CODE �c <br /> cA z� 369 - x{75 sU <br /> TO INDICATE p CORPORATION INDNOUAL p PARTNERSHIP p LOCAL-AGENCY p COUNTYAGEWY p STATE-AGENCY p FEDERAL#GENL <br /> osrHcrs )' (� <br /> TYPE OF BUSINESS a ( GAS STATION p 2 DISTRIBUTOR IF INDIAN RESERVATION I x OF TANKS AT SITE E.P.A. I.0.s(PprgWl <br /> p 3 FARM = A PROCESSOR 5 OTHER OR TRUST LANDS / <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional ',( <br /> DAYS: NA (LAST,FIRST) PHONE A WITH AflEA CODE DAYS:NAME(LAST,FIRST) 1 <br /> � ,osA�,/ G-ovoe �z�N - �S <br /> NIGHTS: NAME(LAST.FIRST) PHONE A WITH AREA CODE NGHTS: NAME(LAST,FIRST) NTH As A COOP <br /> H qF <br /> 11. PROPERTY <br /> /OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAzz-AeME / /G /�J- /f'�Q'GL CAPE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS C ✓bm bAbbaM p INpVOVAL pLOCAL-AGENCY p STATE AGENCY <br /> IO cG u FF vG . p GDUNTY AGENCY <br /> _ p <br /> CORPORATION p PARTNEPSMP p FEOERAUAGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE Of ADDRESS INFORMATION <br /> rd <br /> MAILING OR ST-REE/T ADDRESS• ✓ 5b bMkaH p INDIVIDUAL p LOCAL AGENCY ` STATE AGENCY <br /> /v 'V- Z vF� ✓E- p CORPORATION p PARTNERSHIP p COUNTY"AGENCY E)ERAL AGENCY <br /> CITY NAME - STATE ZIP CODE PHONE A WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 it questions arise. <br /> TY(TK) HO _K - <br /> L <br /> 41n�� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Eos binAlab I SELF INSURED 'p 2 GUARANTEE p 3 INSURANCE p' t SURETY SONO <br /> p 5 LETTEROFCREDIT p 6 EXEMPTION p 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or IL is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L a II.O III. <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 6 SIGNATURE) APPLICANTS TITLE GATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION R can <br /> LOCATION CODECPTIONAL CENSU2$TRACT OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> �/- �✓ <br /> THIS FORM MUST BE ACCOMPANIED 13YREY AT LEAST(1)OR MOPERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12 et) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS I � <br /> � ��/. <br /> f[/ 1 f:7 ( �f I `rpR00 A6 <br />