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OIL) yoo9 <br /> a TATE OFCALIFORIIA FID 6563 A <br /> STATE WATER RESOURCES CONTROL BOARD s <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE pet&Q IQ ,jOSO(pD `���a•�'' <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLSSS��ITTTnEEE���/ <br /> ONE REM 71 2 INTERIM PERMIT Q A AMENDED PERMIT 6 TEMPORARY SITE CLOSURE pertF2 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> COs r VA tlilll S-,tcrt)n <br /> ADDRESS ` C NEAREST CROSS STREET PARCELA(OFOONAU <br /> 8 i 4✓l.CVLr 11�` T C<\hl7�lf e S ✓ <br /> CITY NAM ( ^ STATE <br /> ZIP CODE 0,5 <br /> SITE PHONE a WITH AREA CODE <br /> k Sz <br /> BOX CORPORATION INDIVIDUAL M PARTNERSHIP QWMIAfCY E71 CWMYAGENCY' STATE-AGENCY' O FEDEMLAGENCY' <br /> TOIN DISTRICTS' <br /> N owner al UST Is a public agency,Mnplete,the following;name of Supervtor of dNiebn,section,or office which Operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR RE/ IF INDIAN is OF TANKS AT SITE E.P.A I.D.a repea al <br /> Q 3 FARM Q 4 PROCESSOROTHER ORATION <br /> TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME 1 rill S ter\ \ CARE OF ADDRESS INFORMATION <br /> la <br /> MAILING OR STREET DRESSn ✓box tlnaoas D INDIVIDUAL 0 LOCAL-AGENCY D STATE.AGENCY <br /> ZS - `FA` 1`GCYC7 OCORPORATION D PARTNERSHIP COUNTYAGENCY FEDEMLAGENCY <br /> CITY NAME STATE ZIP CODE HONE•WIT AREA CODE <br /> �� , FCL 9sz©Z 20 � <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bmtedtals INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> O CORPORATION PARTNERSHIP O COUNIYAGENCY O FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE;s WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-T4--]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bmtirdicete 0 I SELF-INSURED O 2 GUARANTEE 3 INSURANCE O A SURETY BOND <br /> O 5 LETTEROFCREINT D&EXEMPTION D 99 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 c d. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.Q II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&S IGNED) OWNERSTITLE DATE MONTWOAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION s FACILITY it <br /> ® 00 (415-0 60 <br /> LOCATION OODE -OPTp�� CENSUS TRACTS -OPTIONAL SUPVISOft-DIST TCODE -OPTIONAL yw-/ (/ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUNn STORAGE TANK REGULATIONS <br /> FORM A(3/113) FORDM' 97 <br /> sew- <br />