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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD •`• -<��i� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A <br /> Y/ <br /> ry. <br /> COMPLETE THIS FORM FOR EAC CILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER SED SITEONE REM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ B TEMPORARY SITE CLOSURE " <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME 1 NAME OF OPERATOR <br /> g00RESS 5 Il N AREST CROSS STREET PARCELA(OPTIDNAy <br /> W , ( 'T(n S N <br /> CITU NAME <br /> STATE ZIP CODE SITE PHONE Y WITH AREA CODE <br /> CA 9 5 3-7 5, s= <br /> ✓ RDx 14 <br /> — <br /> TOINDICATE Q CORPORATION INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE.AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF 3USINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN ♦OF TANKS AT SITE E.P.A. I.D.i(cplimal) <br /> D FARM s PROCESSOR 5 OTHER O RESERVATION 3 <br /> Q OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optIonai <br /> DAYS: NAM (LAST,FIRST) PHONE A WITH AREA <br /> CODE ry DAYS: NAME(LAST,FIRST) <br /> �V –7 O—aO _5a�i <br /> NIGHTS: NAME(UST," T) PHONE A WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED , <br /> NAME f CARE OF ADDRESS INFORMATION _ <br /> A-5k vS <br /> Mq:LING UP STREET ADDRESS / 1 I ,� ✓ Oo,Dwra4 Q INDIVIDUAL Q LOCAL AGENCY <br /> El 15 1 t) OM V/ CORPORATION Q PARTNERSHIP FEDERAGENCY <br /> Q COUNTY,IGENCY Q fEOEMLAGENCY <br /> CITY NAME STATE ZIP CODE PHONE•WITH AREA CODE <br /> 5� 6 0--7 g—yP o <br /> Ill. TANK OWNER INFORMATION•(MUST BE COMPLETED) , <br /> NAME OF OWN-ERR C CARE OF ADDRESS INFORMATION <br /> 1 YW D J <br /> MAILING OR STREET ADDRESS ✓ em nwcAM Q INDIVIDUAL = LOCAL-AGENCY <br /> CSTATE AGENCYb i. iI#GECITY NAME OCORPOMTKKI Q COUNTYAGENCY UN <br /> FEDEOY <br /> STATE 1 ,7z/<r <br /> IP COOS < PHONEWITH AREA CODE O <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUM'B'ER•Call(916)3��23nn-9�5}555�if questions arise. �� <br /> TY(TK) HQ 4 4 Ne<✓j (_GC.O�L�-�� I i '° l_7, 7 f <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓0PxtW ICM Q I SELF-INSURED 0 2 GUARANTEEQ ] INSURANCE <br /> Q 5 IETrEROFCREDIr 0 N 6 EICEWM Q I SURETY BOND <br /> 9P OTNER <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 A80VE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L[:] IL❑ IIL❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY)OVCWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED A SIGNATURE) APPLICANT'S TITLE DATE MONITH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY t JURISDICTION t FACILn•Y• <br /> LOCATIONCOOOE -OPipNAL CENU qA TA O T`O� ' D SUPVI <br /> SUM-DISTRICT CODE -OPTpNAL <br /> THIS FORM 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 15.91) <br /> FORIp]ik5 <br /> � � Sc0llG �� <br />