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1.00 <br /> a STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH ILITYISITE <br /> MARK ONLY � 1 NEW PERMIT � 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED WIL <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE g� <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMENAME OF OPERATOR <br /> / 1,116u --/-e W C <br /> ADDRESS 9 NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> S�� �riri CA o <br /> BOX <br /> TOINOICATE CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP D LOCAL-AGENCY O COUNTY-AGENCY O STATE-AGENCY O FEDERALAGEWY <br /> TPoCTS <br /> TYPE OF BUSINESS O 1 GAS STATION [=] 2 DISTRIBUTOR O ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.#(nplimal) <br /> RESERVATION J <br /> Q 3 FARM O 4 PROCESSOR 6 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 /> / /r O - S d 3 <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> S �/1 <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> --rem <br /> MAILING OR STREET ADDRESS ✓ box bindica 0 INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> /O t-j D CORPORATION PARTNERSHIP 0 COUNTY AGENCY D FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE■WITH AREA CODE <br /> NST � � 9'Ys-sem <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING OR STREET ADDRESS ✓box bintlkaN 0INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> I�CORPORATION D PARTNERSHIP D COUNTY.AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4-F4-1- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCI ESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boz biMiUN 1 SELF-INSURED O 2 GUARANTEE 3 INSURANCE L__]4 SURETYBOND <br /> O 5 LETTER OF CREDIT S EXEMPTION O 99 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 cher <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= IL U. <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 MONTHIDAWYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# ��/J7y <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRx;T CODE -OPTIONAL C .2__80 3 �o L <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. <br /> FORM A(5-91) FORIMS <br />