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STATE OF CALIFORNIA a <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETETHIS FORM FOR EACH F IrwsrrE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 53 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) J <br /> DBA OR FACILITY NAME - NAME OF OPERATOR <br /> v t -SQ' � <br /> ADDRESS y NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> / r <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> TO INDICATE O CORPORATION (] INDIVIDUAL O PARTNERSRIP O LOCAL.AGENCY O ODUNTY-AGENCY STATE-AGENCY Il FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 3 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF IRESERVATION NDIAN #OF TANKS AT SITE E.P.A. L D.#IbDIiaMQ <br /> 0 3 FARM Q ♦ PROCESSOR Q 5 OTHER OR TRUST LANDG <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) AREACOOF <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bW b9bbbA Q INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> (]CORPORATION (]PARTNERSHIP =COUNTY-AGENCY FEDERAL AGENCY <br /> CITY 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 /> To- <br /> MAILING ORSTREETADORESS ✓ EP�biMiplA INDIVDUAL = LOCAL AGENCY Q STATE-AGENCY <br /> l ry/C S� 0 CORPORATION Q PARTNERSHIP 0 COUNTYAGENCy O FMERAL-AGENCY <br /> CITY NAME STATE LP CODE PHONE#WITH AREA CODE <br /> SL,9C-4 1915-2-o9 -) p9 - g <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. a <br /> TY(TK) HO 4 7 btS <br /> V. PETROLEUM UST FINANCIA ESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> J Eo[b4�taM 1 SELFINSUREO =2 GUARANTEE 0 3 INSURANCE Q 1 SURETYBOND <br /> E:;H <br /> O 5 LETTEROFCREDIT Q 6 EXEMPTION a 99 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 /> CHECKONE 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&SIGNATURE) APPLICANPSTRLE DATE MONTHDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It FACILITY a <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> a3 3a <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) FOROW3///A 5��- <br />