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-I �eo�4 e <br /> STATE OF CALIFORNIA .r °, <br /> STATE WATER RESOURCES CONTROL BOARD a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w m� y: <br /> �i <br /> COMPLETE THIS FORM FOR EACH .ACILITYISITE <br /> MARK ONLY F-1T NEW PERMIT F—] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT [:] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACTYNAME NAME OF OP ATOR <br /> Q <br /> ADDRESS D /'N - NEARESTCRO STREE��� PARCEIA(OPfgNAq <br /> CITY MA r✓,A E - STATE 21P CC% SITE PHONE%WITH AREA Co <br /> TOI/ Box <br /> INDICATE CORPORATION Dl•/CCORPORATION 0 INDIVIDUAL = PARTNERSHIP O LOCAL AGENCY (Q�COUNTY-AGENCY Q STATE AGENCY 720/DOIFFEEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. 1.D.%(optional) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR Q S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PVONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> OZEB h�/di�l�/� Poa -7 <br /> NIGHTS: NAME(LAST.FIRST) PHONE%WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE 4 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> v-.yoi2 0l Ga. <br /> MAI/L�pIG/O/R STREETADORESSSS /�/ ^ ���- ✓ bobiMioMe INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> /` 7 Wl�i�yj�j�� ////v�J - JdV CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL AGENCY <br /> CITY NAME STATE ZIP'ODEPHONE%WITH AREA CODE <br /> 111. TANK OWNER INFORMATION•(MUST BE COMPLETED) GGII// <br /> NAMEOE OWNER CARE OF ADDRESS INFORMATION <br /> ^/tvoa— Oyu e.0 <br /> MAILINGORSTREET ADDRESS <br /> // �y� ✓bmblMkaN = INDIVIDUAL I� LOCAL-AGENCY STATE AGENCY <br /> tD ,orl�Jr� `.CJI /J r`4 CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATEAZI�� PHONE x WITH AREA CODE <br /> IV...BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER--Call(916)323-9555 if questlons arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box b Indic* E�]i SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> =5 LETTEROFCREDIT 0 6 EXEMPTION Q 93 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.O it.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&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCISTjOt�CODE -OPTIONAL CZ-5 TUCT SUPVISOR-DISTRICT CODE -OPTIONAL ��� <br /> THIS FORM MUST BE ACCOMPANIED GBBY.AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESSJHIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(S91) /j FOflOp77A5 <br />