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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A <br /> COMPLETE THIS FORM FOR EAC ACILITYISITE <br /> MARK ONLY Q 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT A AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DSA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCELf(OPTIONAU <br /> 3706 E- Go�[.TE.e neo . <br /> CITY NAME �� STATECA Z�COtZ� jTE �` aWrTHI AREACODE <br /> TO INMATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCALAGENCY Q LCOUNTY#GENCY Q STTAAATTEto-V_AGENCJY Q FEOE36 <br /> v BOX <br /> RAL#GENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR gESERVADIAAN f OF TANKS AT SITE E.P.A. I.D.a(optimal) <br /> Q 3 FARM Q A PROCESSOR 0 5 OTHER OR TRUST LANDS TMO <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 /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CQU <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMEp� CARE OF ADDRESS INFORMATION <br /> TFT <br /> MAILINGORSTREET ADDRESS .1Oo[binOkaM Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> 706 O`( Q CORPORATION 0 PARTNERSHIP IQ CWMYAGENCY FEDERAL-AGENCY <br /> CITY A 14T STA ZIP CODE �� P Ea WI'51>c LADE 37 <br /> 4- 1 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) JGq( 6 <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> ATielli't-fX (dv T S'To <br /> MAILING Ofl STREET ADDRESS I=b INSNUM Q INDIVIDUAL Q LOCAL AGENCY Q STArEAGENCY <br /> 2 CJ Q CORPORATION Q PARTNERSHIP Q COUNTY,AGENCY Q FEDERAL AGENCY <br /> CITY NAME 2VZIP 00 P WITH A CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HC1 4 4 -� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Aon niMka,e Q I SELF INSURED Q 2 GUARANTEE Q 3 INSURANCE Q A SURETY BOND <br /> 0 5 LETTER OF CREDIT Q S EXEMPTION Q N 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 130X INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L Q II.F_� III.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 a JURISDICTION at FACILITY# <br /> LOCATK)NCODE -OPTIONAL CEN$U�TMCTA -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL B Z L <br /> PIP <br /> OOCT <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SRE INFORMATION ONLY. <br /> FORM A(5-91) /7, / FORa11 S <br />