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•°b�.. o <br /> STATE OF CALIFORNIA +, <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EAC AOLITWSITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY;A � NAMEOF <br /> Q�Z� �i!✓w`A, �� OPERATOR <br /> rfWSo�: <br /> ADD NErET <br /> PARCEL$(OPTIONAL) <br /> CSTDPPCODE SITE PHONE x WITH <br /> AREA CODE <br /> `A <br /> ,1•I`.��A".4� of SZZd 368•^570-7 <br /> 15 <br /> BOX <br /> TO INDICATE D CORPORATION INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY 0 COUNTYAGENCY STATE-AGENCY 0 FEDERAL#GENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS �I 1 reC STATION O 2 DISTRIBUTOR 0 <br /> RESERVATION <br /> INDDIAN #OF TANKS AT SITE E.P.A. I.D.#(oplbnal) <br /> FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAM (LAST.FIRST) PHONE#W1T ;7C DE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) J\PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME 4r—m 0*729A ` CARE OF ADDRESS INFORMATION <br /> MAI//LggING ORpSTREFFET ADDRESS U ✓box bindiwleINONIOUAL l 1 LOCAL-AGENCY 0 STATE-AGENCY <br /> JJQ`• � P..V/4- I�CORPORATION O PARTNERSHIP D COUNTY-AGENCYQ FEDERAL-AGENCY <br /> CITY NAME �� S� ZIP fAD��� H #WIT D � <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box biWbale INDIVIDUAL <br /> [7:1 LOCAL-AGENCY STATEAGENCY <br /> 7,0P?-1 D CORPORATION O PARTNERSHIP D COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE, ZIP CODE P ONE#WITHLREA CODE <br /> o//7�T— -\]l0 0G JC07 <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 /> ✓ bDXW 1 CM Q I SELFINSURED E-1 2 GUARANTEE [::13 INSURANCE O d SURETY BOND <br /> D 5 LETTER OF CREDIT L::]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.[j�f- 111.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAM E(PR INTED&SIGNATU RE) APPLICANTS TITLE DATE MONTWDAYYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRCTCOIDE - DO L <br /> 3. ZZ 1p �.7 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE NFORMATION ONLY. Y <br /> FORM A(5-91) A FOR0033A 5 <br /> 4 /� T <br />