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STATE OF CALIFORNIA �� <br /> STATE WATER RESOURCES CONTROL BOARD :mom' r. <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A •; <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 'o�„„� <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLO <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME �-7 NAME OF OPERATOR <br /> c L. e u <br /> ADDRESS s. NEAREST CROSS STREET PARCELN(OPTIONAL) <br /> crfnAmE <br /> STATE ZIP CODE SITE PHONE N WITH AREA CODE <br /> CA y(o�o' <br /> ✓BOX CORPORATION t::] INDIVIDUAL Q PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY- STATE.AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE X DISTRICTS <br /> Nomrerof UST'sa public agwWy,complete the blown&name of supervisor ol EMeun,section or office Nch op mm the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓IF INDIAN NOF TANKS AT SITE E P.A. L O N(optAmO <br /> RESERVATION <br /> ❑ 3 FARM ❑ a PROCESSOR00, 5 OTHER pR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(UST.RR T) ��O N WITH AREA CODE DAYS: NAME( ,RRS[ PHONE N W�dAREA CODE,,_ <br /> 33 <br /> NIGHTS: NAME(LAST,FIRS ) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p 9WH ARIA CODE <br /> It 11 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLF'TFD) <br /> NAME CAREOFADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bub rdaa E:3 INDIVIDUAL Q LOCAL-AGENCY (] STATE-AGENCY <br /> []CORPORATION =PARTNERSHIP COUNTY-AGENCY [] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF WN R� . CAREOFADDRESS INFORMATION <br /> MAILING OR STREET ADOR SS ✓ bo.lo YWiote INDIVIDUALO LOCAL-AGENCY O STATEAGENCY <br /> DN a cos O CORPORATION (]PARIHERSHIP COUNTY-AGENCY FEDERAL.AGENCY <br /> CITY NAME STATE ZIP CODE PHONE NOWT AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. {T/!/a <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box tordomi =1 1 SELF-INSURED O 2 GUARWME =3 1NSURANCE O A SURETY BOND =5 LETTEROFCREDR I=6 EXEMPTIONI�T STAT FFUND <br /> =8 STATE FUND&CHIEF FRANC&OFFICER LETTER 09STATE RIND&CERTIFICATE OF DEPOSIT O 10 LOCALGOVT.MECHANISM =' OTHEP <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 BILUNG: 1.❑ tl.❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MYKNOKEEDGE,IS TRUEAND CORRECT <br /> TANK OWNER'S NAME(PRINTED A SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY Rem To/ <br /> COUNTY N JURISDICTION N FACILITY N, 6 D <br /> V..J.J_JJ <br /> LOCATIO OD -OPTIONAL CENSUS TRACT -OPT/O AL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> OLnY1`/ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORMS,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM- -H THE LOCAL AGENCY IMPLEMENTING THE UNDERGROI' '-IDRAGE TANK REGULATIONS <br /> FORM q(6-95) ^ J q 9 *V-i� <br /> VU 7l ✓if/Y7 <br />