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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK?ERPLICATION - FORM A <br /> 0 <br /> COMPLETETHISFOR FOR C ACI YISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 C NGE OF INFORMATION ❑ T PERMA l- IT <br /> ONE ITEM ❑ 2 INTERIM PERMIT Xa AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME N OF PERATO i ^ f <br /> a c a5 0 e,h <br /> Q�� NEAREST CROSS ST EET PARCEL#(OPTK)NAL) <br /> 420 li{J • �i N r), 2�8 080. 0 <br /> CITU NAME STATE ZIP CODEITE PHONE x WITH AREA COD <br /> 1^�G CA a5'yl� coq ftj 2 ' `L <br /> ✓ Box <br /> TO INDICATE O CORPOR TION 0 INDIVIDUALPARTNERSHIP LOCAL-AGENCY O COUNTY-AGENCY0 STATE-AGENCY FEDERAL-AGENCY <br /> TYPE OF BUSINESS 1 GAS STATION = 2 DISTRIBUTOR ❑ RESERVATION I / IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 0 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS � 16-al 00 Z <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> q�VS: ME(LAST,FIR T) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> pia hiny �9 4 t� 4 :06 <br /> NIGH S: NAME(LAS ,FI T) PHONE#WITH AREE NIGHTS: NAME(LAST,FIRST) <br /> 7� m�a e� IS - roAREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDR SS INFORMATION <br /> OCAbe �r n c . e - <br /> r95-he-MAILING OR STREET ADDRESS ✓ box lo rdlca O INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> 1-42? COR ION = PARTNERSHIP O COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME ATE ZIP CODE ONE WITH AREA CODE <br /> P <br /> III. TANK OWNER I ORMATION-(MUST BE COMPLETED) <br /> NE,OF OWNER CAR OFA DRESS INFORMATION <br /> a a <br /> AILN ORSTREET ADD ESS ✓ box a 0 INDIVIDUAL D LOCAL-AGENCY 0 STATE-AGENCY <br /> full •it piC �D O CORPORATION PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITU NA STATE ZIP CODE P ONE#WITH AREA CODE <br /> G G O . 6 - 2 <br /> IV. BOARD OF EQUALIZATI <br /> UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 If questions arise. <br /> TY(TK) HO 14141- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box blrAicale 0 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE l=1 A SURETY BOND <br /> D 5 LETTEROFCREDIT O 6 EXEMPTION N OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. it.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PR INTED B SIGNATU RE) APPLICANT'S TITLE DATE MONTWDAYNEAR <br /> OCAL AGENCY USE ONLY <br /> COUNTY# 01 It//1 JURIS�# �� FACILITY# <br /> (VAIllf/(/ It 3 3 <br /> LOCATION E -OP l_ CENSUSTRA T# -/OPTNAL SUPVISOR-DISTR CT CODE -OPTIONAL <br /> 651 <br /> MUSf BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORMIB,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(5-91) FOR0033A-5 <br />