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0 0 <br />STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD <br />^a aezou -°0i <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />o <br />� a <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE A °a,.o ��. <br />MARK ONLY ❑ I NEW PERMIT yl <br />ONE ITEM 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ <br />❑ 2 INTERIM PERMIT PERMANENTLY CLOSED SITE <br />LJ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O/ <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />AD`2692'5—S"DI11 11 1 111 F <br />y' ��reZZy3 '� ��a�n.�/,�,� <br />NA FOP RATOR <br />UhU �! D /�Q NEARES�ROSS"TREET I <br />✓ Box <br />TOINDICATE <br />I- I INDIVIDUAL 0 PARTNERSHIP L:1 <br />CA <br />TYPE OF BUSINESS ❑ ❑ LIS I RICT! <br />7 GAS STATION 2 DISTRIBUTOR O <br />O 3 FARM O 4 PROCESSOR 0 5 OTHER 1 <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />DAYS: NAME (LAST,FIRST) <br /># <br />III. TANK OWNER INFORMATION - (MUST BE <br />WITH <br />C COUNTY AGENCV 0 STATE -AGENCY 0 FEDERALAGENCY <br />INDIAN # OF TANKS AT SITE E. P. A. I. D. # /mrim�u <br />erinni <br />JET LANDS ` <br />EMERGENCY CONTACT PERSON (SECONDARY) • optlon.I <br />-�" LJ INDIVIDUAL 0 LOCAL AGENCY <br />0 CORPORATION0 PARTNERSHIP E:] STATE -AGENCY <br />COUNTY -AGENCY 0 FEDERAL -AGENCY <br />IT&= sn......._ <br />CARE <br />I i"U' =AL L J LOCAL -AGENCY 0 STATE AGENCY <br />O CORPORATION 0 PARTNERSHP 0 COUNTY -AGENCY <br />,TAZIP CODE O FEDERAL <br />IV. BOARD OF EQUALIZATION[UST STORAGE FEE ACCOUNT NUMBER • Call (916) 323-9555 if questions arise. <br />TY (TK) HQ LQ 115 1 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY -(MUST BE COMPLETED) —IDENTIFY THE METHOD(S) USED <br />✓ box b intlicale iSELF INSUREDLK 0 2 GUARANTEE <br />5 LETTER OF CREDIT L] 6 EXEMPTION 0 3 INSURANCE 0 <br />VI. LEGAL NOTIFICATION AND BILLIE-1 99 OTHER <br />NG ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II i h <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />PPLICANT'S NAME lPRlNicn a cirun T. ��, <br />LOCAL AGENCY USE ONLY <br />3 <br />COUNTY # <br />9 JURISDICTION # -I- f <br />'\ CENSUS TRACT# - OPTIONnr- -_- — — <br />FACILITY # <br />d SURETY BOND <br />ry <br />THIS FORM MU BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION • FORM B, UNLES THIS IS A CHANGE OF SITE INFORMATION ONLY, <br />FO RIO A 112.911 FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />0 <br />f� � ')_0 K � FOR0077A fl6 <br />