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STATE OF CALIFORNIA a� `eoo. - °o <br /> STATE WATER RESOURCES CONTROL BOARD ig <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A W ve <br /> �G , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °�o.°.m�. <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT S CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBp ORFACILII �� NAMEOFOPERATOR <br /> /ADgORPv��s/V� NEI�iEST CROS$$? PARCEL#(OPFpNAu <br /> CITY NAME G <br /> STATE ZIP CCODETE PHONE#WITH AREA CODE <br /> Gd CA ,Z�o J <br /> ✓ BOX <br /> TO INDCATE CORPORATION D INDIVIDUAL PARTNERSHIP LOCAL-AGENCY 0 COUNTYAGENCY 0 STATE-AGENCY D FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN I#OFTANKSATSITE E.P.A. I.D.IF(optimal) <br /> 3 FARM <br /> RESERVATION �J7 <br /> Q O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> �4eo <br /> NIGHTS: ME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> Z/- T <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxb E:1 INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> �j COBPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE HONE#WITH AREA CODE <br /> �07UZ-6l / iv��/a7- Z6 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRESS ✓ box 10 Indicate 0INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION ] PARTNERSHIP E�j COUNTY-AGENCY ] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITHAREACODE <br /> 2i'�/� <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO K-41-101001,,5101 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bintlbak E:::] 1 SELF-INSURED 2 GUARANTEE E�:j 3 INSURANCE O d SURETY BOND <br /> 0 5 LETTEROFCREOIT O S EXEMPTION = W 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.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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> C3T 3 1445l;5 Sv <br /> VTION CODE -OPTIONAL C;7;TR -OPTIONAL SUPVISOR�STRICT CODE -OPTIONAL qL <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 />