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BOUR <br /> A/ STATE OFCAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD �, .. ... <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e <br /> G COMPLETE THIS FORM FOR EA H FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O ] PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT F-1 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE S <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> c1wLe.-f- <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAW <br /> !So E• oar <br /> CITY NAME - �* STATECA �IP CODE SITE PHONEN WITH AREA CODE <br /> BOX <br /> TOINDICCATE L--I CORPORATION (]INDIVIDUAL 0 PARTNERSHIP f7 LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY (]FEDERAL AGENCY <br /> DISTRICTS <br /> 11 <br /> TYPE OF BUSINESS O I GAS STATION O 2 DISTRIBUTOR RESERVATDION OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> 0 3 FARM O 4 PROCESSOR 0 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 /> PHONE a WITH AREA <br /> NIGHTS:NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> /w T1-fe Arffi <br /> MAILING ORSTREET ADDRESSi ✓box b Intkb# 0 INDIVIDUAL E] LOCAL-AGENCY0 STATE-AGENCY <br /> 57000 g7 0 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEaPDXITHAREACODE <br /> ek4t,PJ CY3 -$o&0 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CAR OFADDRE FORMATION <br /> MAILING OR STREET ADDRESS ✓ Wx0mkale = INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> P-0. 50 Q 0 CORPORATION = PARTNERSHIP E COUNTYAGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE WITH AREA CODE <br /> eklaN 52oS— <br /> IV.BOARD OF EQUALIZATIONU <br /> �ISTTSST�ORR�AG�E FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 -0ZOL?1--Z4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bm blMkn I� I SELF INSURED 0 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> D 5 LETTER OF CREDIT O 6 EXEMPTION W 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.L-] 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(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> /3�iL7EL,z1 <br /> LOCATION COOE -OP7IOV4L CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT BBBC- -iPJiBMgL <br /> __ C <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORMLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) <br /> /FORW33A-5 <br />