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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD `4 � �� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A r� <br /> Ix <br /> y; . <br /> COMPLETE THIS FORM FOR EACH F NYISRE <br /> MARK ONLY 1 NEW PERMIT S RENEWAL PERMIT CHANGE OF INFORMATION 7,86WAAMEWLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT A AMENDED PERMIT O B TEMPORARY SITE CLOSURE If <br /> 7 J <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> /AP l NAME Of OPERATOR <br /> ADDRESS / ,y 1 A16/_r lIA/^!/ NEAREST CROSS STREET PARCEU(OPTIONAU <br /> CITU NAME STATEDP SITE PHONE A WITH AREA CODE <br /> CA <br /> TOIN Box Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY (' Q STATE AGENCY Q FEDERAL44ENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR ,'RESEF INDIAN A OF TANKS SITE E.P.A. L D.A(oadmal) <br /> Q ATO <br /> O FARM Q a PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS:NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: AME(UST,FIRST) a p5—j <br /> S 2 J?iv Son g <br /> NIGHTS: NAME(LAST.FIRST) PHONE XWITH AREA CODE NIGHTS: NAME T.FIRST) <br /> PPON5 I WITH ARC A COnC__ <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME ^' o C CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADO(ESS / ✓ Ibt bmium Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Om nimgm Q INDIVIDUAL Q LOCAL AGENCY Q STATE AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDEPALAGENCY <br /> CITY NAME STATE I LP CODE PHONE I WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Cal((910)323.9555 if questions arise. <br /> TY(TK) HQ F4_74 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓�bY1ReaM Q I SELFINSUREO Q 2 GUARANTEE Q 7 W CE R SURETY ECND <br /> O 5 LETTEROFCREDT O$EXEMPTION OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.D ILO 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 A SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x -JURISDICTION a FACILITY x <br /> LOCATION CODE -OPTro7L (CENSUS SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FOR B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. /(_ <br /> FORM A(5A1) FORMA5 7 <br />