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I <br /> I �- <br /> r STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ;? ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> . . o <br /> COMPLETE THIS FORM FOR EACH ILITV/SITE <br /> MARK ONLY F—] 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O ] PERMANENTLY CLOSED SITE <br /> k ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE Z <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBA9a CILITYNAME V / NAMEO�RA�� NvLli <br /> ADDRESS r``//!!''// NEAREST CROSS STREET PARCEL#(OPTIONA) <br /> j 70v ti . G /DC7 / <br /> -71&44-4 sT <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Se10, n�1 cA q�ZV <br /> T 10 NDICATE O CORPORATION 0 INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN 1101 TANKS AT SITE E.P.A. I.D.#(001&a) <br /> RESERVATION <br /> O 3 FARM Q 4 PROCESSOR Q 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 /> N77 �LIlU <br /> NIGHTS:NAM l l(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> c144fFrjilo <br /> MAILING OpRJST�RE,ET ADDRESS �+ ✓bo4blydk Q INDIVIDUAL LOCAL-AGENCY (�STATE-AGENCY <br /> '7C7 �O YaDQJ �L 000RPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> siv -b�J � GT5Zv7 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Z144f �r ES ZNC . <br /> MAILING�pO'RyySTREET ADDRESS ✓bmblr&b 0 INDIVIDUAL LOCAL-AGENCY [7)STATE-AGENCY <br /> �p� <br /> 14v Y 11A/ CORPORATION 0 PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> 7l�/4 Zv <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4-1-4]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ hoa birAkak 0 1 SELF-INSURED 2 GUARANTEE O 3 INSURANCE 4 SURETY BOND <br /> 0 5 LETTEROFCREDR Q S EXEMPTION O 92 OTHER I <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II. III. I <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 MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION M FACILITY x <br /> LOCATION COpE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> � 20 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• F M B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A IS 91) FOFWWlA5 <br />