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esoo• e. <br /> STATE OF CALIFORNIA os <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ;a m ae <br /> o. <br /> C MPLETE THIS FORM FOR EA fAgLITYISITE <br /> MARK ONLY 1 NEW PERMIT D RENEWAL PERMIT 5 CHANGE OF INFORMATION 77 ] P NENTLY D SITE <br /> ONE ITEM 2 INTERIM PERMIT 6 AMENDED PERMIT Ij 6 TEMPORARY SITE CLOSURE s <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILI NAM NAME OF OPERATOR <br /> c .dam T <br /> ADDRESS I NEAFIESF CROSS STREET i PARCELr(OPTO6A4 <br /> CITY NAM ST CA n90 Z� SI SNE/;3 /— zl/O <br /> ro INMATE O CORPORATION �I INDIVIDUALINDIVIDUALPARTNERSHIPv p LOCALAGENCY GOODUNTYAGENCY C STATE-AGENCY _YPEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O I OAS STATION GI 2 DISTRIBUTOR 0 RE1 IF INDION Is OF TANKS AT SITE E.P.A. L D.N Ioatl ? <br /> S FARM �i A PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> GAYS: NAME(LAST.FIRST) PHON r WITH AREA D D NAME(LAST/ ,FIRST) ` 9 � ^0 <br /> 3 o� <br /> NI H A,E(LIST.FIRS1) PHONE r3W13TH A=CODE NIGHTSG�LQ�y1�LVIT.FIRST) ) �J`! �� 2 z- <br /> -IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> CARE OF ADDRESS INFORMATION <br /> MAU OR STREET3pDRESS q ✓ boA EinEitalr n INDIVIDUAL J LOCAL AGENCY f1 STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP o COUNTYAGENCY = FEDEMLAMNCY <br /> CITY NAME TEA n� F. PHONE A WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER RE OF ADDRESS INFORMATION <br /> MAIL( OR�SSTREET DRESS ✓ EOIbOtlew I� INDIVIDUAL �_ LOCAL-AGENCY STATE AGENCY <br /> . � d CORRORATgN Q PARTNERSHIP J CGUNTYAGENCY FEDERALAGENCY <br /> CITY NAME STATTT nP COD^ PHONE r WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9565 if questions arise. <br /> TY(TK) HO ;14 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ C�Micate I SELF-INSURED 2 GUARANTEE 6 INSURANCE A SUPE7BONG <br /> 5 LETTEROFCREDIT J 6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II Q checked. <br /> OHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: LJ II.I III.( <br /> THIS FOAM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE-IS TRUE ANO CORRECT <br /> APPLICANTS NAME(PRINTED A SIGNATURE) APPLICANT'S TITLE DATE MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY �75 <br /> COUNTY a JURISDICTIONN FACILITY k <br /> 3 -� / 5 LI � <br /> _CCAATIONR E OPTIONAL CENSUS TRACT -OPTIONAL SUPVISODISTRICT CODE -OPTIONAL <br /> 0.5 . <br /> THIS FORM MUST BE ACCOMPANIED BY AT LF ASST 17)OR MORE PERMIT APPLICATION--g�FGO/RM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FILE THIS FORM WITH T�:LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STOP AGE TANK REGULATIONS //�/ <br /> Fdi0077AA6 <br /> low `f <br />