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., Esc ow 4 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i u <br /> 1 C / UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A W <br /> •�'�Ow Y`w <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENT CLOSED SITE <br /> ONE ITEM L] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE '"2— <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> FADDRESS <br /> I TYNAME NAME OF OPERATOR <br /> �Gr e_`C�'O✓I I17In VL <br /> L- NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> S (0 5fr CS t410,1 tk o (� <br /> STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> 7c,v BOXATE CORPORATION D INDIVIDUAL =PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY STATE AGENCY FEDEHAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR / IF INDIAN RESERVATION #OF TANKS ATTKE I E.P.A. I.D.#(00maq <br /> ❑ 3 FARM 4 PROCESSOROTHER 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) PWnMP WITH ARPA MOP <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PWONF WITH AREA CODF <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMECARE OF ADDRESS INFORMATION <br /> .d4 S q- a ,C -Soy, <br /> MAI,INGOSTRE <br /> RETADDRESS /1 O ✓bomind� D INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> s OC5C CORPORATION PARTNERSHIP Q COUMYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AflEA CODE <br /> s cG o� ern $32 �3 &- _ 24y <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box bindbaN I] INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> (�CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <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 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ boa 0kxi a O 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE D 4 SUR Ett BOND <br /> D 5 LEREROFCREDR O 6 EXEMPTION O 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 NAM E(P R IN TED&S IGNATURE) APPLICANTS TITLE DATE MONTWDAYNFAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# �FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> o a -sem <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS I A E OF SITE INFORMATION ONLY. <br /> FORM A(5 91) FORMA 5 <br /> %.-., \./ 5 <br />