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bbOJF f <br /> STATE OF CALIFORNIA - �� <br /> P� s <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :�� ,�° <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLYNEW PERMIT O 3 RENEWAL PERMIT E 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSE4 SITE <br /> ONE ITEM 2 INTERIM PERMIT � 4 AMENDED PERMIT 0 e TEMPORARY SITE CLOSURE ©2 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR F44j 17 ME {/��1 NAME OF OPERATOR <br /> 1/'/G/G// <br /> ADORES I ,W . <br /> /' _ �1 NEI RE TCROSS STREET PARCEL#(OPTIONAL) <br /> W ri / I <br /> CITY NAMSTATE ZIP COOG6� SITE PHONE i WITH AREA CODE <br /> CA <br /> I/ BOX <br /> TO INDICATE D CORPORATION 1 INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY D COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR RE/ IF INDIAN SERVATION #OF TANKSJ�T SITE E.P.A. I.D.#(Wicnal) <br /> Q 3 FARM O 4 PROCESSOR = 5 OTHER 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) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS Eaa b Wbab O INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> O CORPORATION E::] PARTNERSHIP COUNTYAGENCY [_�] FEDEML#GENCY <br /> CITY NAME - STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS boa biWica4 INDIVIDUAL D LOCAL-AGENCY E-1 sTATEAGENCY <br /> O CORPORATION PARTNERSHIP 0 COUNTY-AGENCY [--] FEDERAL#GENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE <br /> FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 14R]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP TED)—IDENTIFY THE METHOD(S) USED <br /> ✓Sw biMbab O I SELFINSURED =OUARANTEE O 3 INSURANCE 0 A SURETY BOND <br /> O 5 LETTER OF CREDIT EVS EXEMPTION 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: I.E IL O 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(PRINTED a SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNFAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 6I JURISDICTION# FACI <br /> L�- � f <br /> LOCATION CODE 6TTTONAL CENSUS TRACT# -3T10 L� SUPVISOR-CIS[ <br /> RICT CODE -OPTIONAL <br /> 1 <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FOR B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOROM; 5 <br />