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yours e <br /> STATE OF CALIFORNIA `t <br /> STATE WATER RESOURCES CONTROL BOARD. o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> ,nONN'` O <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION F-� 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F-1 2 INTERIM PERMIT Q 4 AMENDED PERMIT 0 e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> .L siol / <br /> ADDRESS NEAREST CROSSS REET PARCEL#(OPTIONAL) <br /> /E ToA.e /? <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓ Box <br /> TO INDICATE O CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY D COUNTY-AGENCY 0 STATE-AGENCY D FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 1 GAS STATION 2 DISTRIBUTOR 0 '/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#Iap6cnal) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR E] 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 6kje-f isew <br /> MAILING OR STREET ADDRESS - ✓booblydkYe E-1 INDIVIDUAL 0LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP <br /> PCCODE <br /> / PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWN <br /> CARE OF ADDRESS INFORMATION <br /> /N nV <br /> MAILING 00STREET ADDRESS ✓ boabindkab INDIVIDUAL 0 LOCAL-AGENCY D STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME� STATE ZIP CO��/ PHONE#WITH AREA CODE <br /> Cd I <br /> IV.BOARD_OF EQUALIZATION UST STORAGE FEE ACCOUNT NU ER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boo binEkak D I SELF INSURED 0 2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND <br /> O 5 LETTEROFCREDIT 0&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 11 is ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.pf III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAM E(PH INTED&SIGNATURE) APPLICANTS TIRE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# —- <br /> ® a s ca•Nc��� <br /> LOCATION CORE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIO <br /> f .2 3. 3 Zr /d 9/ <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. CA,'N <br /> F RMAlS-91) 0 FORW33A5 <br />