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♦ <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE y1 1 <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 RMANENTNTLY CLOS <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT 6 TEMPORARY SITE CLOSURE y <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME ^ _ NAME OF OPEI7ATOR <br /> j'$/ NEAREST CROSS SET PARCEL 0(OPTIONAL) <br /> CITY NAM(T{E� / ` STCi1ryA/Il e1 Z/TR:52ba SITEPHONE07 NE AREA CODE a,- <br /> ✓ BOX 0 CORPORATION ;01DMWAL O PARTNERSHIP O LOCA-AGENCY Cl COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> X pwnar d UST e e puMc agM=vIme PH 10Mwa10:name of supervisor of dwis ,swion woEm wNp1 operates Iw UST <br /> TYPE OF BUSINESS a 1 GAS STATION O 2 DISTRIBUTOR ❑ qE I IF INDLAN I OF TANKS AT SITE E.P.A I.D.D.6�(osp im.Q <br /> Q 3 FARM Q A PROCESSOR 5 OTHER OR TRUST LANDS A� 0 0;z w[2 9 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> D YS: NAME(LAST,FIR T) I PHONE*WITH A4COD DAYS: NAME(UST,FIRST) PHONE P WITH AREA CODE <br /> NIGHTS: NAME(UST,FIRST) PHONE*WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE I WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME vm CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS- � 110w ba1^dpab DUAL DLOCAL-AGENCY EDSTATE-AGENCY <br /> 2 S �`��a_ �`Jx— 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME �G I`-•� V STAT/E_ 6 <br /> � ZIP CODE PHONE I 1N AgEA <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) `� Vn <br /> NAME OF OWNER CME OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Dmbagiole INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE/WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACC <br /> pUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 - A A- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓OoapirpicaM 0 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 0 e SUREWBMD 0 5 LETTER OF CREDIT 0 6 EXEMPTION O 7 STATE FUM) <br /> 08 STATE FUND&CHIEF FINANCIAL OFFICER LETTER OISTATE FUND ICERTIFICATE OFDEPOSIT 010 LOCAL GOVT.MECHANISM 009 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.❑ �Iz IN.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNER'S NAME(PRINT D&SIGNA E) ( TANK OWNER'S TITLE DATE MONTWDAY/YEM <br /> d� 7 � 21-9 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY I JURISDICTION I FACILITY/ <br /> m <br /> i <br /> LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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. p <br /> OWNER MUST FILES THIS FORM"'4 THE <br /> LOCAL/ / ]/AGGEE''NNCCYY IMPLEMENTING THE UNDERGROV STORAGE <br /> TANK <br /> REGULATIONS <br /> ... FORMA(615)I-e s Y- <br /> -_ a.C.iK WC }^"•� "� �' �K.GLC / I ('�(/1 <br />