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V J a [ <br /> STATE OF CALIFORNIA `i <br /> STATE WATER RESOURCES CONTROL BOARD 3y. <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A "�`� ne <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY T NEW PERMIT ❑ 3 RENEWAL PERMIT Ege ,, CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME 11 1 NAME OFOPE TOR/ L <br /> {( fIAC IC LIA �C . jT Q� <br /> G� <br /> ADDRESS <br /> NEARE.V CROSS <br /> $TBEET PARCEL 0(OPrIONAL) <br /> CIN NAME STATE ZIP CODE SITE PHONE#WITH AREA DODE <br /> I/ Box CA 66 - c z9/ <br /> TO INDICATE ORPoRATION INDIVIDUAL 0 PARTNERSHIP (] LOCAL-AGENCY 0 COUNTY-AGENCY l= STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR O ,/ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#[apNonal) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOROTHER OR TRUST LANDS Z <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIR 11 PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> 6 N ' �, <br /> 700- 975;. PHONF 2 WITH AREA-mg <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE f WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> e sL <br /> MAILING O STREET RESS ✓ boa bintlbau INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> 0 63S Q CORPORATION ] PARTNERSHIP CWNTVdGENCY FEDERAL-AGENCY <br /> CITY NAMESTAT/EA, ZIP CODE PHONE 0 WITH AREA CODE <br /> o4 la66 5 !r- 29 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS V WXOIki 0INDIVIOUAL LOCAL-AGENCY STATE AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP (]couNrY.AGENCY FEDERAL#GEWY <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 Lol 7,1 t4 I'l O <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓boa 0WC&M 0 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> 0 5 LETTEROFCREDIT O 6 EXEMPTION E-1 93 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: I.O II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PH INTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/OAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# �� <br /> ® [ 6S] <br /> LOCATION CODE -OPTIONAL CENSUSTRACT# -OPTIC <br /> NAL SUPVISOR-DIS ICT CODE -OPTIONAL <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(5-91) FORM3A5 <br />