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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD f`•••o-•-,��' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ro o <br /> MARK ONLY ❑ _ <br /> 1 NEW PERMIT ❑ 7 REN <br /> ONE REMPERMIT <br /> _ —EW�F� T _s CHANGE OF INFORMATION ❑ T PEq <br /> ❑ 2 INTERIM PERMIT' -❑ l AMENDED PERMIT CLOSED SITE <br /> -- -- ❑ a T1=AIFIORARV SITE CLOSURE .. D <br /> I. ACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DB CR FACILITY NAME <br /> 'I 01 j / NgME OF OPERATOR <br /> A RESS st I ('•(�l C H9tr3 <br /> el <br /> W, fNEAREST CROSS STREET I PARCEL•(OPIONAL) <br /> CITU NA E <br /> ST TEZIP CO SITE PHONE t WITH AREA COOS <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL Q PART RSWP Q LOCAL-,AGENCY Q cOUNTY.AGENC C <br /> Q STATE-AGENCY FEDEML.GENCYDISTRICTS <br /> TYPE OF BUSINESS I STATION 2 DISTRIBUTOR ✓ IF INDIAN !OF TANKS AT SITE A. I p.•IgN�mY/ <br /> Q 7 FARMa PgOCESSOR 5 OTHER O RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) - - EMERGENCY CONTACT PERSON (SECONDARY)•optlonal <br /> DAYS: NAM ( Tr ST) PHONE.2Z <br /> WITH ACCIi DAYSSNAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST.FIRS PFIONE a WITH DARE CODE NK TS: NAME(LAST.FIRST) <br /> • c <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME <br /> �A - 'lj u j� J� C� C�E OF ADDRESS INFORMATION <br /> MAILING DR TRE ADDRESS J7 (� J [✓._bw oinaeal• Q IN IVUAL I^ <br /> JLOCAL-AGENCY Q STATE-AGEIrY <br /> CITY NAME 61) M7 Q CORPORATION Q PARTNERSHIP Q COUNTY,AGENCY Q FEDERAL.1 RACY <br /> STATE ZIP I/a PHONE•WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE a'MPtfi€D)_ <br /> NAME OF OWNER w CARECF ADDRESS INFORMATION <br /> W <br /> MAILING OR STREETADDRESS ✓ Oo•EyIPkaY Q INDIVIDUAL <br /> Q LOCAL AGENCY Q STATEAGENCY <br /> Q CORPORATION Q PARTNERSHIP Q CWNTY.AGENCY Q FEDERAL,AGENCY <br /> CITY NAME STATE ZIP CODE PHONE•WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(9 16)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bw bvdE Q 1 SELF-INSURED Q 2 GUARANTEE <br /> Q 5 LETTER OF CREDIT Q7 M URMNLE •SURETY SONO <br /> Q 1 EXEMPTION OTHER /- <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will tHf sent to the tank owner less box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 14 114 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS UE AND CORRECT <br /> APPLICANTS NAME(PRINTED 6 SIGNATURE) APPLICANTS TIRE DATE MCNTFMAYrfEAR <br /> LOCAL AGENCY USE ONLY U5 <br /> COUNTY�+ M A^� �51 JURISDICTION t FACILITY 8 <br /> LOCATION CODE - nOML CENSUS TRACTA -OPTIONAL SUPVISOR•DISTRICT CODE -OPTIONAL <br /> FCAM ASe ORM MUST 8E ACCOMPANIED BY AT LEAST(tJ OR MORE PERMIT APPLICATION- FOR B,UNLESS THIS IS A CHANGE OF 1 ORJM(TION ONLY. <br /> THI � / FaarDAa <br />