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STATE O <br /> STATE WATER RESOURCESURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY t NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLO ITE <br /> ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT O a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION b ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ZAAX /1-CA/0 <br /> ADDRESS NEAREST C SS STREET PMCEL#(OPTIDNAL) <br /> ev V C tr/ <br /> CITY NAME S / STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> yoC ./1CA <br /> I/ BOX <br /> T NDICATE D CORPORATION O INDIVIDUAL 0 PARTNERSNP LOCAL-AGEWY 0 COUNTY AGENCY' D STATE-AGENCY' -rJ reueML#GENCY' <br /> DISTRICTS' <br /> N owner d UST Is a pudic agency,complete the following:name of Supervisor of tlluabn,section,or oaice which operates the UST <br /> TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTORO ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.#(gWbW) <br /> RESERVATION CI <br /> 0 3 FARM Q 4 PROCESSOR 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) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) AS <br /> PHONE a WITH AREA CODE NIGHTS: NAME(LT,FIRST) PHONE i WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAVE CARE OF ADDRESS INFORMATION <br /> MAILING OR STREEr ADDRESS ✓Oa bbEkate 0 INDIVIDUAL O LOCAL-AGENCY O STATE AGENCY <br /> O CORPORATION O PARTNERSHIP 0 COUNTYAGENCY 0 FEDERAL-AGENCY <br /> COY N ` / STATE ZIP CODEPHONE a WITH AR CODE <br /> n ZO z 1 F-7 b <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ ism bintlkaN INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> S,00 51,11 CORPORATION O PARTNERSHIP Q COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME SITE ZIP CODE Z PHONE#WITH AREA CODE <br /> )i(o 46-7 06 - arz_ 6 -306 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-[4--]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boloadome =1 SELF-INSURED L-1 2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND <br /> E-1 5 LErrEROFCREGT =S EXEMPTION D W 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.[_-] III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT �I <br /> OWNER'S NAME(PRINTED S SIGNED) OWNER'S TITLE DATE MONTROAYIYFAR n <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> Y 5 � <br /> LOCATION CODE -OPTIOMLC (CENSUS TRACT# -OPTIONAL SUPVISOR-DIS ROT CODE -OPTION& <br /> <`/ gZ-z L 2- ",-3 <br /> THIS FORM MUST BE AccbMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,mllfss THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3'93) OWNER <br />