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40 UA <br /> STATE OF CALIFORNIA ^rr °i, <br /> STATE WATER RESOURCES CONTROL BOARD s` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W `� �s <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F-1 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION = 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME NAME OF P ATOR <br /> . C. rA OIn+.A <br /> ADDRESS �s NEARE/gTCROSS STREET PARCEL#(OPTIONAL) <br /> I 'i JO O S led C(cc 0. S — —Q <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> S-Fx cA 45 -0 lv .zaq_ yb6-32s L <br /> TOINgC TE O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR 0 ✓ IF INDIAN a1 OF TANKS AT SITE E.P.A. I.D.#(op#an#e <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) I�IYPHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> Cef m sF J0 k" 2o?- -37-92 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PI4QN9#WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> ss e a+N In+c <br /> MAILINGORSTREET ADDRESS ✓ box binGW# O INDIVIDUAL O LOCAL AGENCY 0 STATE-AGENCY <br /> A0 1 6008' CORPORATION 0 PARTNERSHIP O COUNTY AGENCY ] FEDERALAGENCV <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> S e of520.6 —UD <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> GS �� <br /> MAILING ORSTREET ADDRESS ✓ box bine 0INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP O COUNTY-AGENCY 0 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]- (3 (0 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bor blMlkzte 0 1 SELF-INSURED 0�GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> D 5 LETTER OF CREDIT V6 EXEMPTION 0 N 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.O II.z 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(PR INTER&SIGNATU RE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# F <br /> T S 7 8111 oZ. <br /> LOCATIONCODE -rTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> —1=!r 23. FID 3-Z.3 a <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) FORiRiX3-3A 55 <br />