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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD mom, '.460UPCt <br /> , �''�� <br /> -ANDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �e <br /> COMPLETE THIS FORM FOR EACH ILITYtsITE <br /> MARKONLY T NEW PERMIT 0 3 RENEWAL PERMIT E945 CHANGE OF INFORMATION O T PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMR O e TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS /cep <br /> NEAREST STREET PARCEL#(OPTIONAL) <br /> 4! / W/ / Af. <br /> CITY NAME STATE ZIP CODE SITE PHONE x WITH AREA CODE <br /> 172a A ,/.cam CA <br /> BOX <br /> TO INDICTE [--I CORPORATIO L--1INDIVIDUALI=PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY (] STATE-AGENCY Q FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O >16ASSTArION 0 2 DISTRIBUTOR 0 RE/ IF INDIAN SERVATION #OF TANKS AT SITE E.P.A. I.D.x(optimal) <br /> E61(3 FARM 0 4 PROCESSOR = 5 OTHER ORT ST LANDS / <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAPHONE A WITH AREA GnnF <br /> YS: NAME(LAST.FIRST) PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> a /JI �/ / - S'a7-���a Sa#Nv <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> SR .,LA SG.wPHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET.ADDRESS ✓box 10 O INDIVIDUAL O LOCAL AGENCY (1 STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY Q FEDERAL-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION• (MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 5' ..ca .[ S aL <br /> MAILING OR STREET ADDRESS ✓box Wntlkata INDIVIDUAL LOCAL-AGENCY 0STATEAGENCY <br /> O CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 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 4 4 D i a d .9 & <br /> V. PETROLEUM UST FINANCI ESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Eox blMkala 1 SELF INSURED O 2 GUARANTEE 0 3 INSURANCE 4 SUREN BOND <br /> 5 LETTEROFCREDIT O B EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless b I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.Z 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 NAM E(PR IN TED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY �1 <br /> i <br /> COUNTY# JURISDICTION# /A„[�co)-�j ' FACILITY FI-1-11 <br /> 9 FT= +' 3 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE - L <br /> _____�) <br /> .Z.3 z <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOROOOOA 5 <br /> C n <br />