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,e.a�a <br /> STATE OF CALIFORNIA r "' `i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> �� re UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W m� n <br /> COMPLETE THIS FORM FOREACH LRYISITE <br /> FMARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOS QQ <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS �� �� NEA ST GROSS STREET PARCEL M(OPfgNAI) <br /> CITY NAME H STATE ZIr/PGC TEP NE#WITH AREA CODE <br /> G opz CAv BOX <br /> 9a <br /> TO INDICATE D CORPORA N INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY Q STATE AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR 0 RESERVATION It OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS' NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> 'USE i 3 <br /> 6 <br /> NIGHTS: NAME(LAST, IRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> /'fes ls�ll <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREE;;DRESS ✓box 1,nd a D INDIVIDUAL O LOCAL-AGENCY STATEAGENCY <br /> J• O CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY (] FEDEML#GENCY <br /> CITU NAME STATFj ZIP C(�E� I�� P ONf't W H AREA CODE <br /> 0 lc�r./4J- GJa /� J\ <br /> III. TANK OWNER INFORMATION• (MUST BE COMPLETED) <br /> NAME OF OW NE CARE OF ADDRESS INFORMATION <br /> MAILGG OR STREET ADDRESS ✓ box blMbam O INDIVIDUAL LOCAL-AGENCY STATE AGENCY <br /> CORPORATION [�j PARTNERSHIP COUNTYAGEWY 71 FEDERAL-AGENCY <br /> CITY NAM STATE ZIP COD,.— HONE It WITH AREA CODEQ�O <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(9166))3323-9555 if questions arise. �7rlJ <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box blMbate 0 1 SELF-INSURED 2 GUARANTEE Q 3 INSURANCE =1 4 SURETY BOND <br /> (] 5 LETTEROFCREDIT 6 EXEMPTION N 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 <br /> APPLICANTS NAME(PR IN TED&S IGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOTION CODE -OPTIONAL CENSUS TRACOPTIONAL - E -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICA - �RM B,UNLESS THIS IS A CHANGE OF SITE INFORRMAT . <br /> FORM A(5-91) �; A'5 <br />