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W11101 *100 <br /> 0Un <br /> STATE OF CALIFORNIA i <br /> STATE WATER RESOURCES CONTROL BOARD �6 '; <br /> c <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W m� v o <br /> COMPLETE THIS FORM FOR EAC AGILITY/SITE <br /> MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT EVS CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE K <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) V <br /> D4qRFACILITYN E NAMEOFOPERATOR <br /> I s u1!liq 5erviC2 <br /> ORES NEA19EPTCROSS STR ET PARCEL#(OPrIONAL) <br /> badr yr 9-2 D -7/47 72 <br /> CITY NAME STATE ZIPS/TD�� ITE PHONlE#WITH AREA CqDE <br /> 15/�KCA {NN55 p <br /> ✓ BOX <br /> TO INDICATE D CORPORATION VrINDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O I GAS STATION O 2 DISTRIBUTOR r0 ✓ IF INDIAN IXOF TANKS AT SITE E.P.A. I.O.#(optimal) <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION <br /> (] � OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST.FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Il. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NA CARE OF ADDRESS INFORMAT N <br /> MAI G RST EETADDRE ✓ box blM is INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP (]COUNTY-AGENCY FEDERAL-AGENCY <br /> CI E STAj� _ ZIP COjTE��� PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) l//'r/(/ —/f/ <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box I,Num OINDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 -II <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box b indkaN O I SELF-INSURED =^ARANTEE 0 3 INSURANCE 0 4 SURE7YBOND <br /> O 5 LETrER OF CREDIT 5 EXEMPTION = 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' hecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.O it. III.O <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) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> S-?] ? i�c 4 1 1101-ro <br /> LOCATION CO OP77ONAL CENSUS TRACT IION4 SUPVISOR-DIST ICT CODE -OPTIONAL <br /> THIS FORIJ MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR6;A-5 1 <br /> \/� <br />