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• • <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ # AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME 7 NAME OF OPERATOR <br /> / w vOC /l ,v <br /> ADDRESS NEAREST CROSS STREET PARCEL e(OPTOKAL) <br /> 7-�" <br /> CITY NAME _ STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA d9 D 2 0170 <br /> ✓BOX =CORPORATION = INDIVIDUAL PARTNERSHIP =LOCAL-AGENCY =COUNTY-AGENCY' STATE-AGENCY' = FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> low roi USTgepabkaguayoampleteteelogowng:lame dsWer%word dimion,sedan or office which openda the UST <br /> TYPE OF BUSINESS EE!'1 GASSTATION Q 2 DISTRIBUTOR ✓IFINDIAN #OFTANKSATSITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM O # PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST PHONE#WITH AREA CO E DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> u� f a� 077 r�i.or�� <br /> NIGHTS: NAME(LAST,FIRST PHONE#WITH AREA CODE I NIGHTS: NAME(LAST,FIRST PHONE#WITH AREA CODE J <br /> o oT ! wi /�F •1o7`/�T3�%a D oo— J'h'� ' Tl� y zT <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Z <br /> MAILING OR STREET ADDRESS //- C',CI n,'J 7, Z��' ✓ �b n6rale 0 INOMDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> J O =1 CORPORATION [PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 111AREA CODE <br /> 147 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxloeidaete = INDIVIDUAL =LOCAL-AGENCY = STATE-AGENCY <br /> =CORPORATION [5TARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ 4 4 -�3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to lrGaale <br /> [E!r_1 SEUNNSURED = 2 GUARANTEE E` 3 INSURANCE O<SURETY BOND =5 LETTENOFCREDR =6 EXEMPTION =]STATE FUND <br /> =6 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =#STATE FUND&CERTIFICATE OF DEPOSIT 010 LOCAL GOVT.MECHANISM = 99 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: 1.[!�r it.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANKOWNER'STITLE DATE MONTH/DAYNEAR <br /> J'oz <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION# FACILITY# 04- <br /> ✓— <br /> —t- <br /> LOCATIONCODE -OPTIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 /> FORMA(6-95) OWNER MUST FILE THIS FORM)THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUJORAGE TANK REGULATIONS <br />