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STATE OF CALIFORNIA °sem <br /> STATE WATER RESOURCES CONTROL BOARD `4 R <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FORE H FACILITYISITE <br /> MARK ONLY F-] 1 NEW PERMIT 3 RENEWAL PERMIT EV 5 CHANGE OF INFORMATION 0 T PERMANENTLY CLOSED SITE <br /> ONE ITEM [_] 2 INTERIM PERMIT 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE Sd <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME AME OF OPERATOR <br /> IN <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> .Z[SO E <br /> CITY NAME STATEZIP CODE SITE PHONE AREA CODE <br /> CA <br /> ✓ BOX <br /> TO INDICATE E-1 CORPORATION E-1 INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY Q STATE AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESSO 1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN N OF TANKS AT SITE E.P.A. I.D.#(gNknal) <br /> RESERVATION <br /> 0 3 FARM O 4 PROCESSOR Q 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(LAB 1,FIRS T) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME - CARE OF ADDRESS INFORMATION <br /> C <.1 <br /> MAILING LOUR STREET ADDRESS ✓ bubInEbW I= INDIVIDUAL L-:] LOCAL-AGENCY 0 STATE AGENCY <br /> P. O• Solo O CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Sloe k4.-j ca <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Aga ew)e�Y <br /> MAILING OR STREET ADDRESS ✓ box bintlbaN INDIVIDUAL (] LOCAL-AGENCY D STATE-AGENCY <br /> P. O. A bx chgo O CORPORATION PARTNERSHIP Q COUNTYAGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE 21P CODE PHONE#WITH AREA CODE <br /> S ee or <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 pZ S <br /> iAM51ft MA.vIX9CM M+�- Q <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COM ETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bo:blMicab O 1 SELF-INSURED GUARANTEE O 3 INSURANCE A SURET 1) <br /> 5 LETTER OF CREDIT S EXEMPTION O 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or IIs checked. <br /> CHECKONE BOX INDICATING WHICH ABOVEADDRESS SHOULOSE USEDFOR LEGAL NOTIFICATIONS AND BILLING: 1.E—] 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 NAIVE(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> CrnOUNTY# JURISDICTION# FACILITY# <br /> ai- <br /> LOCATIONCODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> O/ Z3 .5`-C7 .23 <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(S91) FOR=3A-5 a <br />