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• • eaaoun e <br /> STATE OF CALIFORNIA Ae ^ o^ <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITWSITE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE () <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ZaQD <br /> ADDR SDD NEAREST CROSS STREET S'T PARCEL%(OFTIONAL) <br /> CITY NAM STATE 21P CODE $1TEOPHO�NE#WITH A�CODE <br /> li �f,�,// CA rY'+ \J i <br /> v BOX <br /> TO INDICATE L_ycORPORATION INDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> "Xco DISTRICTS <br /> TYPE OF BUSINESS ❑ GAS STATION ❑ 2 DISTRIBUTOR ❑ "' IF INDIAN #OF TANKS AT SITE E.P.A. I.D.%(optlapal) <br /> RESERVATION <br /> 3 FAgM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE# ITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE*WITH ARFA <br /> 72 <br /> NIGHTS:PJAME(LAST,FIRST) PHONE% ITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF AD KESS INFORMATION <br /> I V? GSL Z m ?' y <br /> MAILIINJa OR STREET AWRESS157 ✓ boxblMkab INDIVIDUAL 1= LOCAL-AGENCY Q STATE-AGENCY <br /> J O U X Z&yy CORPORATION PARTNERSHIP =COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY <br /> I _ GC �� �/ STATE ZIP CODEONE#.WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) f IA/� L7D( <br /> NAME OF OWNER CARE OF ADDRESS INF RMATI N <br /> MAILING OR STREETADD ESS -D ✓ bar 0Indkale INDIVIDUAL LOCAL-AGENCY 0 STATEAGENCY <br /> a . &X Zyl�yNnCORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PH E%WITH AREA CODE <br /> f:; ,4 T G 4 I Z�' z"6 J - � 2 g <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ n474 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bindkale O 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> O 5 LETTER OF CREDIT 6 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPUCANTSNAME(PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> C�ODUNNTYj # JURISDICTION# FACILITY# <br /> I / <br /> -J 1-1 111L <br /> LOTION CODE -OPTIONAL CEyS TRACT,s-OPT]ONAL SUP <br /> VIM,VRICT CODE -OPTIONAL !± /d 7THI FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESSTHIS C NGE OF SITE INFORMATION ONLY. <br /> FORMA(5-91) FOR0033A5 <br /> • <br />