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L/ lam( eeou,. � <br /> STATE OF CALIFORNIA �,+ <br /> STATE WATER RESOURCES CONTROL BOARD i �: <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w�� `�° <br /> COMPLETE THIS FORM FOR EA ACILIrY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS&D SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ < AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITVNAME w NAME OF OPERATOR <br /> LK//. a GR. <br /> ADDRESSa ^ ���v NEAREST CROSS STREET PARCEL#(OPTIONAL) — <br /> CITY NAME /•( /`7-1 STATE P ODE SITE PHONE#WITH AREA CODE <br /> CA A/A <br /> TOINOICATE D CORPORATION Q INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY STATE-AGENCY 0 FEDEMLAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR /5 OR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(000I) <br /> 0M <br /> RESERVAT <br /> ,Fee ION <br /> 0 3 FARM � 4 PROCESSOR OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAY - NAME(LAST FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> D ao R S-8 <br /> NIGHTS: NAME(LAST,FIR 1HONE#WITH REA CODE NIGHTS: NAME(LAS 1,FIRST) #WITH AREA Con; <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME na CARE OF ADDRESS INFORMATION <br /> M oro <br /> MAILING OR STREET ADDRESS-E. <br /> ✓OOR bInOk#a (] INDIVIDUAL f� LOCAL-AGENCY �STATE-AGENCY <br /> CORPORATION D PARTNERSHIP COUNTY-AGENCYf� FFEDERAL-AGENCY, <br /> CITU NAE STA ZIP CODE FeONEO�HAREACODE <br /> 0— Ot <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) Fe <br /> ((�� OOcc <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS vmolndkm INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> =CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERALAMNCV <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - D 3 1 o'Z to <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Ow blMeale =t SEURNSURED O 2 GUARANTEE 0 3 URANCE O A SURETY BONO <br /> O 5 LETTEROFCREOT &EXEMPTION Ltelgg 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 Decked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ II. 111.❑ <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&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY A AA 4L Q <br /> COUNTY# JURISDICTION# FA <br /> LOCATIONCO E -OPT/O L CENSUB TB(TCa- O^L SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESSTHISIS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOROW3A5 <br />