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eeoua : <o <br /> STATE OF CALIFORNIA s� <br /> STATE WATER RESOURCES CONTROL BOARD ? <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> rr,, COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY u 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION UV7 PER E CLOSED S <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE0 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> EEJ NAME OF OPERATOR <br /> ADDRESS NEARE ROSS STREET PARCELN(OPTIONAL) <br /> l 9 (r �+rt— <br /> CITYNAME STATE ZIP CODE SITE PHONE S WITH AREA CODE <br /> 5;4vC,k-fv.. CA _ _ <br /> .1 Box <br /> TO INDICATE D CORPORATION INDIVIDUAL = PARTNERSHIP 0 LOCAL-AGENCY O COUNrY-AGENCY E=I STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 1 GAS STATION 2 DISTRIBUTOR = ✓ IF INDIAN 14 OF TANKS AT SITE E.P.A. I.D.•(optimal) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) FHONE DAYS: NAMEILAST,FIRST) <br /> U" 51M PHONE 9 WITH ARFA r�Dp <br /> NIGHTS: NAME(LAST F RST) If PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE 8 WITH AREA COG <br /> �- <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> C/ee.r C r�P <br /> MAILING OR STREET ADDRESS / ✓ box bin irate L__1 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> _ Z "o I{o ay) O CORPORATION I= PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME ST9,]E- ZIP CODE PHONE a WITH AREA CODE <br /> &/rt CL (�� 'l707-25-5mo0? <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> S'a "' e qs -►t <br /> MAILING OR STREET ADDRESS ✓ box bindlcals [=1 INDIVIDUAL E71 LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP l=COUNTYAGENCY 0 FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE%WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. <br /> TY(TK) HQ [4-F4] [�0]3_ JZ L2 <br /> ] <br /> V. PETROLEUM UST FINANCIA SPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ bax biMbala I SELF INSURED = 2 GUARANTEE 0 3 INSURANCE [=1 d SURETY BOND <br /> = 5 LETTEROFCREDIT = 6 EXEMPTION 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 C cked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.0 II. 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 MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It FACILITY A, `}{�N 7y <br /> 31 1 1 1] <br /> LOCATIONCODE -OPTIONAL CENSUS TRACTX-OPTIONALyni SUPVISOR DISTRICTCODE -OPTIONAL <br /> aI 3 Z3 1e s(f_3 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION <br /> FORM A n2.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> RA/�J,\�\ <br />