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STATE OF CALIFORNIA `+. <br /> STATE WATER RESOURCES CONTROL BOARD i 4 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W m� <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY O 3 NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT L] e TEMPORARY SITE CLOSURE 62-- <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> ';A3 <br /> FACILITY NAME NAME OF OPER;kWx—r <br /> ADDRESS i�/'T —C�a N RESR <br /> TCROSS TEET PARCEL#(OPTIONAL) <br /> ZO a2-! f�EldNEf7c,� /d0 <br /> CIjY NAME STATIPCODE SITE PHONE#WITH AREA CODE <br /> Pa CA C7z z 36 g-5o7 <br /> I/ BOX <br /> To INDICATE CORPORATION INDIVIDUAL 0 PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY O FEDEML-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESSO 1 S STATION 0 2 DISTRIBUTOR ✓ IF INDIAN 4 OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME lLAST,FIRST) 1 PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> ArN <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COQP <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE <br /> CARE OF ADDRESS INFORMATION <br /> 5 �#TvRv <br /> MAILING OR STREET ADDRESS ✓ box binEbate INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> , ��� � Q/�.� CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL AGENCY <br /> CITY NAME STA ZIP CODE JPHONE#WITH AREA CODE <br /> ,GGrdcl/>D ci�-- �I�ZLo Z�r� �-So7 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS /' ,/ ✓ boa b Ink" INDIVIDUAL � LOCAL-AGENCY � STATE-AGENCY <br /> d'�' NEFIAe— 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STTAATEE� ZIP CODE PHONE WITH AREA CODE <br /> qt 2-2.1v LD�i� g' 7 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 J <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ boa blMkab 0 1 SELF-INSURED =22GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> O 5 LETTER OF CREDIT 27-6—EXEMPTION 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.O IL a III.O <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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUTNTY# JURISDICTION# EACIUIY <br /> F4 Yri 1 <br /> Yl <br /> LOCATION CODE -OPTTIOON�ALL- CENSUS TRACT# -OPTIONALSUPVISOR-DISTSICTS)ODE -OPTIONAL <br /> `G� <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 /> FORM A(5-91) FOR0033A 5 <br />