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' 1�60V. 1, <br /> STATE OF CALIFORNIA i <br /> STATE WATER RESOURCES CONTROL BOARD ;!6 o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ""� �; <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT E__] 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM O 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE S <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) SS <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> — r <br /> ADDR SS NEAREST CROSS STREET I PARCEU(OPTIONAL) / <br /> ��- 9 <br /> CITY NAME STATE ZIP CODE S PH ES WITH AREA CODE <br /> `� CA Las bq _ 7S <br /> ✓ Boz <br /> TOINDICATE D CORPORATION INDIVIDUAL O PARTNERSHIP D LOCAL-AGENCY COUNTY-AGENCY Q STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR = ✓ IF INDIAN #OF TANKS AT SITE E.P.A. L D.It(optional) <br /> N / <br /> 3 FARM O q PROCESSOR 5 OTHER RESERVATIO <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: H (LAST,FIRSn ��0� pZ0�\#WITH AREA CODE 7� DAYS' NAME(LAST,FIRST) <br /> NIGHTS:'NAME(LAST,FIRST) 1/PH•OrNEE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> ELIQUE I WITH AREA DOOR <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> < ,Sl.4GL <br /> MAILING OR STREET ADDRESS n C ✓ boa blM'rab INDNIDUAL OLOCAL-AGENCY E-1 STATE-AGENCY <br /> 4=G 4, IT/VG O CORPORATION E:1 PARTNERSHIP 0 COUNTYAGENCY <br /> FEDERAL#GENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> md <br /> �5L a <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR ST-REFT ADDRESS• ✓ boa bimicam INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> iU 'V- GG!/�� ✓�- CORPORATION O PARTNERSHIP =COUNrYAGENCY FEDERAL-AGENCY <br /> CITY NAMESTATE ZIP CODPHONE#WITH AREA CODE <br /> G-oi�� C.4- �1• �d <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ �4—T-4-1u-[:]�� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Los 0indcale O 1SELF-INSURED =12 GUARANTEE 0 3 INSURANCE [-14 SURETY BOND <br /> 5 LETTER OF CREDIT [—] 6 ExEmFnON (_J 99 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.E] 11.❑ III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAM E(PR IN TED A SIGNATU RE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# PA <br /> LOCATIONCODE -OPTIONAL CENSU TRACT# -OPTIONAL SUPVISOR-DIGTRICT CGDE -OPTIONAL <br /> Z 32v . <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(12 91) FILE THIS FIRM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR003 A6 <br />- <br />