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E. <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD z 1 <br /> UND STORAGE TANK PERMIT APPLICATION • FORM A <br /> UNDERGROUND <br /> C . " . <br /> COMPLETE THIS FORM FOR EACH FACILITYSITE <br /> MARK ONLY u 1 NEW PERMIT 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION 7 PERMANENT' SITE <br /> ONE REM (j 2 INTERIM PERMR O A AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �J <br /> I. FACILI TYISITE INFORMATION 3 ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> NAME OF OPERATOR <br /> Tse u� ,�. , <br /> ADDRESS N• AREST CROSS STREET FARCEL;IO;;I <br /> a/Y Dv <br /> CIT'NAME STATE ZW CODE SITE PHONr[ (iTDDIN BOX LI CORPORATION O MOVDUAL O PARTNERSHIP O LO AGENCY O COUIRY'AGENCY O SLATE-AGENTYPE OF BUSINESS I GAS STATION O 2 DISTRIBUTOR 0RESFIFF INNDIIAANN #OF TANKS A7 SITE E.P.0. <br /> O 9 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) PHONE;WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHOW P WITH AREA CODc <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS EMbNtlKaN O WWMML [ LOCALAGENCY STATE-AGENCY <br /> p CORPORATlcN ED PARTNERSHIP E:]COUNIYAGENCY a FEDEFAL-AGENCY <br /> CITY NAME (STATE I 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 ///y .1 On bbtlbiN =INDIVIDUAL ED IDCAI-AGENCy E3 STATE.AGENCY <br /> C / <br /> 7 > / H •h/'I V - O DORPORATON =PARTNERswP p COUNry wi NCY O FEDERALAGDYY <br /> CITY'NAME SN C Vu rv..PA�o I STATE I ZIP CODE PHONE r WITH AREA CODE <br /> l/1� yS <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323.9555 g questions arise. <br /> TY(TK) HO 71474 -L0 l21�� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Ow bVdraY J 1 SELF-INSURED u 2 GUARANTEE J ] INSURANCE A SURET BOND <br /> 5 LETTER OF CREDIT =6 EXEMPTION L•F 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[:j II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* JURISDICTION# FACILITY* MI--'7, 0j <br /> T <br /> LOCATION CODE -OPTIONAL (CENSUS TRACT; -OPTIONAL ISUPVISOR-DISTRICT CODE -OPTIONAL <br /> 1 k <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) F�FCGSAd <br />