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i <br /> ��// STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> C•I�nOYY`• <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY T NEW PERMIT F7 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CL ED ST` <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT O6 TEMPORARY SITE CLOSURE O I <br /> I. FACILRYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> A Ifni 9 o T <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA 533J -23 <br /> T INDICATE0 L CORPORATION 1 INDIVIDUAL D PARTNERSHIP O LOCAL-AGENCY (�COUNTY-AGENCY Q STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN 14 OF TANKS AT SITE E.P.A. 1.D.#(aptlarW) <br /> RESERVATION <br /> 0 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS AME(LAST,FIRST) PHONE#WITH AREA CODE/ DAYS: NAME(LAST,FIRST) <br /> ([� JI M S- Sc0_ L3 J PHONE A WITH AREA <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 8 WITH AREA <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME C' CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS 1 / /A' ✓ boa 0ImicaN INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> 16 7S I1 CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME r STATE ZIP CODE PHONE#WITH AREA OCDE <br /> La i- 4S33a- 2 �5�r- 23-3 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 1 <br /> MAILING OR STREET ADDRESS ✓ Ooa biMicW INDIVIDUAL 0 LOCAL-AGENCY sTATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP (] COUNTY-AGENCY FEDERAL- <br /> AGENCY <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 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Sm blMkare O 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND <br /> O 5 LETTEROFCREDT 8 EXEMPTION 0 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 cherkod <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L E] 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(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILrrY# M_4-UTE fro <br /> eT I I I I I So <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 3- <br /> THIS FORM MUST BE ACCOMPANIED AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(591) FOR0033A 5 <br />