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J ' <br /> STATE ovCALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD >` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> r� o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE I ATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FE - NAMEOFOPERATOR <br /> v ca�f Cod <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATEZIP CODE SITE PHONE A WITH AREA CODE <br /> CA �Zo I/ Box ?SCD — c <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHP I]LOCAL-AGENCY Q COUNIYAGENCY Q STATE-AGENCY Q FFDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATIONQ IF INDIAN 0 OF TANKS AT SITE E.P.A. L D.R(aWbW) <br /> 0N Q 2 DISTRIBUTOR <br /> RESERVATION <br /> 0 3 FARM O 4 PROCESSOR Q 5 OTHER 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( WITH AREA r.QQF <br /> FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODF <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME GI CARE OF ADORES.INFORMATION <br /> u (s <br /> MAILING OR STREET ADDRESS ✓ t=bkwi Q INDIVIDUAL 0IOCALAGENCY STATE-AGENCY <br /> 0 CORPORATION Q PARTNERSI9P Q COUNTY,AGENCY Q FEDERALADENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> GJ�Y— Cj¢ C-1-- 1 373 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) 3v `� _�j5—/5S <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bmnNdlm* Q INDIVIDUAL Q LOCAL-WANCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNIY44ENDY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE•WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HO F4-F4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ boy bv4leab Q 1 SELFINSUREO Q 2 GUARANTEE Q INSURANCE Q 4 SURETY BOND <br /> Q 5 LETTER OF CREW =S EXEMPTION Q 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: L❑ 11.❑ 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(PANTED b SIGNATURE) APPLICANTS TIRE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* JURISDICTION a FACILITY a SX' Lc.7 y y <br /> a <br /> LOCATION CODE -OPTIONAL CENSUS TRACT?OPTIONAL SUPVISOR-DISTRICT LADE -OPTIONAL Z3 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)VOR MORE PERMIT APPLICATION• FORM BB,,f-UNLESS THIS IS A CHANGE OF srFE INFORMATION ONLY. <br /> FORM A(5-91) FOR=3A.5 <br />