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STATE OFCALIFORWA i <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ S RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE / <br /> I. FACILRYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DSA OaEAQLITY NAME NAME OF OPERATOR <br /> C r Oe � <br /> ADDRESS I NEAR ST CROSS STREET I PARCEU(OFRONAU <br /> CITY NAME STATE ZIP CODE SITE PHON WITH AREA CODE <br /> CAv BOX <br /> C -� <br /> TOINpOATE C0RPORATION 1E INDIVIDUAL 0 PARTNERSHIP Q LOCAL-AGENCY Q COUNTYAGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 90 STATION ❑ 2 DISTRIBUTOR ❑ R V IF INDIIAN ON x OF TANKS AT SITE E.P.A. L D.*(apdcnQ <br /> FARM 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> :NAME( ST,FIRST) PHO 0 ITHAREA CODE _ DAYS: NAME(LAST.FIRST) <br /> O <br /> IGHTS: NA E( T,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> SLAY)i/TI Lp— PHONE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME L CARE OF ADDRESS INFORMATION <br /> l <br /> MAILING!OR STREET RESS �� ✓ Iba birbkala Q INDIVIDUAL 0 LOCAL-AGENCY O STATE AGENCY <br /> 01 I 0 CORPORATION 0 PARTNERSHIP Q COUNTY#GENCY Q FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE I PHONE WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ baa0 Mbam INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP Q COUNTI-AGENCY C3 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-T74 - <br /> a a <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa b Wk" Q 1 SELF-INSURED E:]2 GWAMEE Q 3 INSURANCE O a SURET/BOND <br /> O 5 LETTEROFCREDR EXEMPTION 0 N OTHER <br /> 71 <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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ 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 /> C� fl ODUNNa,T..�YY# JURISDICTION# FFZ)j �A, ILC�ILITYY(# <br /> `...c' -" `tea—"i' <br /> LOCATIONTAONAL NSU RACTA -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> a s. aa_. a <br /> THIS FORM MUST BE ACCO P�EDRE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> A(`t91) -_ - FOR0077A-5 <br /> NOW <br /> , <br />