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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> . r7 . 1 d <br /> rtl; <br /> COMPLETE THIS FORM FOR EACH F Y/SITE <br /> MARK ONLY ❑ NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE [t O <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) a <br /> DSA OR FACILITY NAME NAMEOFOPERATOR <br /> f�a C . <br /> ADDRESS NEARESTCROSS$TREET PARCEL 0(OPfIONAL) <br /> f04- <br /> 10 0 <br /> CITY NAME OY STATE LP CODE SITE PHONE s WITH AREA CODE <br /> S <br /> ✓ BOX CA fdr>/ d9 — 1,!66 - -11i <br /> TO INDICATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNIY-AGENCY Q STATE AGENCY Q FEDERAL,AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Q I GAS STATION DISTRIBUTOR Q "' 1,F INDIAN #OF TANKS AT SITE E.P.A. L D.#(IP buo <br /> RESEVATION <br /> Q O FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•options] <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> yo�P-L4 glen Sr✓ rl - Y6 6—.Sr7!/ So,1.10 <br /> NIGHTS: NAME(LAST HHS F) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> Su .r t <br /> PHONE 9 WITH AREA COOF <br /> II. PROPERTY OWNER INFORMATION• UST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Ve �Z4 <br /> MAILING OR STREET ADDRES ✓OOO bY#icW Q INOIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> O R�GJ Q CORPORATNNL Q PARTNERSWP Q CWNLT AGENCY Q FEDERILAGENCV <br /> CITY NAME STATE 21P CODE PHONE s WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> .SrGnOC orS q w.— <br /> MAILING ORSTREET ADDRESS ✓OOR bifgiCYAQ INDWIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNIYAGENCY Q FEDEMI#GENCY <br /> CITU NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 it questions arise. <br /> TY(TK) HQ F4-T47- <br /> V. <br /> r7 PETROLEU <br /> 4 -V. PETROLEUM UST FINAA ETH <br /> ESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE MODS) USED <br /> ,/ NCIIm b YIIkW I SELF-INSURED - Q 2 GUARANTEE Q I INSURANCE Q 4 SURETY BOND <br /> 0 5 LETTEROFCREDIT Q 6 EXEMPnON Q II OBER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L II.❑ III,O <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 MONTHIOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> F371 isa <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 3 a-a <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 /> FORM A(&91) <br /> _ FON(NOOAS <br />