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.. Nu,. <br /> STATE OF CALIFORNIA �. �`. <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�"� y: <br /> e s.I , o' <br /> c„•Pry,. <br /> y COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT S CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM a 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSUREG <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME /rL NAME OF OPERATOR <br /> _ <br /> ADDRESS NEAREST CROSS STREET PARCELa(OFTIONALI <br /> 6 Fj'�D � rS�c-f�✓� <br /> CITY NAM STATE FzIP�COOE <br /> SITE PHONE#WITH AREA CODE <br /> /�A-44100 CAv BOX <br /> T NDCATE O CORPORATION Wy INDIVOUAL C—] PARTNERSHIP 0 LOCAL-AGENCY C] CWNrY-AGENCY 0 STATE-AGENCY Q FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESSO T $STATION Q 2 DISTRIBUTOR O R ESERVATV IF INNDIa OFT AT SITE E.P.A. L D.a ropIknap <br /> ION <br /> ZI 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) HONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> z (- <br /> - • CS �s�- qo4 <br /> NIGHTS:NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS w -/ bum WE W�-7RDIVDUAL Q LOCAL-AGENCY (]STATE-AGENCY <br /> -5-Af4/1v1%rr O CORPORATION <br /> = PARTNERSHIP ED COLINP CODENIYAGENCYY FEDERALAGENCY <br /> A CODE <br /> CI NAME_! /PSTAT LIGf/�-TW?jHV <br /> IIL TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWN RR � CARE OF ADDRESS INFORMATION <br /> MAILING ORSET ADDRESS INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY <br /> 0 CORPORATION O PARTNERSHIP Q COON YAGENGY FEDERALAGENCY <br /> CITY NAM;OtZ:fW STATE ZIP CODE --T-PE E#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 -101-510-1 Z <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ b�P i bka!a CD I SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE Q A SURETY BOND <br /> O 5 LETTER OF CREDT Q 6 EXEMPTION O 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 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 A SIGNATURE) APPLICANTS TITLE DATE MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTKNI# FACILITY# <br /> 0 6 61 <br /> z 6� <br /> LOCATION CODE -OPTIONAL (CENSUS TRACT -OPnONAL SUPVIBOR-DISTRICT CODE -OPTIONAL <br /> THIS FOR MUST BE ACCOMPANIED BY AT L[E/ACSSTT(1)OR MORE PERMIT APPLICATION-- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION'ONLY. <br /> FORM A(5.91) FORDU <br /> w <br />