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0 <br />s STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY ® 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSP <br />ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE rro <br />L FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />NAMEOFOPERAT R <br />I�hE G'vsfortER Co <br />6 <br />tin/ 0 -�y - <br />ADDRESS <br />NRESTCROSSSTREET <br />PARCEL#(OPTIONAL) <br />92- at <br />PHONE # WITH AREA CODE <br />07-745-66q/ <br />.ToAA/6olV .T Al 07-7gE-66Q/ <br />CITY NAME <br />STATE <br />ZIP CODY <br />SITE PHONE # WITH AREA CODE <br />rap <br />CA <br />CITY NAME <br />No i vef <br />✓ BOX CORPORATION 0 INDIVIDUAL O PARTNERSHIP O LOCAL -AGENCY 0 COUNTY -AGENCY' 0 STATE -AGENCY' O FEDERAL -AGENCY' <br />TO INDICATE DISTRICTS <br />'Homer N USTB apu* agency, mmplele the folbwnT.. re ofsupoMwrolaNLsn,sectionorotrnexhito 08$the UST <br />TYPE OF BUSINESS1 GAS STATION 2 DISTRIBUTOR <br />® <br />❑ ✓ IF INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />FMFRr-FNnY rnNT&rr pFRcnN (PRIMARY( EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRSPHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />tin/ 0 -�y - <br />6 <br />- �fS 664/ <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />/VES <br />PHONE # WITH AREA CODE <br />07-745-66q/ <br />.ToAA/6olV .T Al 07-7gE-66Q/ <br />DSCoE <br />ZIP CODE <br />9ySlU <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAMECARE <br />Cus foM ee <br />OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box loildcate Q INDIVIDUAL <br />O LOCAL -AGENCY O STATE -AGENCY <br />P 0 Re? x 936 <br />(K CORPORATION [:1 PARTNERSHIP <br />Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITU NA E <br />STATE <br />Ca <br />ZIP CODE <br />9ySlU <br />D <br />PHONE # WITH AREA CODE <br />707.7119-669/ <br />6Ni,l,L <br />C:1 FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />21P CODE <br />9ys/o <br />III TANK OWNFR INFORMATION - (MUST BE COMPLETED) <br />NAMEOFOWNER pp <br />CARE OF ADDRESS INFORMATION <br />I.tS D ER C D <br />MAIDNGOR STREET ADDREESSG <br />✓ bmtondimte Q INDMDUAL <br />Q LOCAL -AGENCY <br />ED STATE -AGENCY <br />D <br />L9 CORPORATION ED PARTNERSHIP <br />O COUNTY -AGENCY <br />C:1 FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />21P CODE <br />9ys/o <br />PHONE #WITH AREA CODE <br />-7 YS -664/ <br />,y/C, 4L <br />IV, BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322.9669 if questions arise. <br />TY (TI) HQ 4 4- 8 1 8 5 9 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED <br />✓ box to indicate 1� 1 SELF-INSURED 0 2 GUARANTEE [::] 3 INSURANCE [-] 4 SURETYBONO 0 5 LETTEROFCREDIT O 6 EXEMPTION ® 7 STATE FUND <br />Q 8 STATE FUND& CHIEF FINANCIALOFRCER LETTER Q 9 STATE FUND& CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT. MECHANISM ED 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 />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. ❑ it ® III. ❑ <br />L� THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUEAND CORRECT <br />TANK OWNER'S NAME (PRINTED & SIGNATURE) TANK OWNERS TITLE DATE MONTHIDAYNEAR <br />QcyoeiS'l/Scti(za�P 9/w1cR ICu a os -/y 48 <br />LOCAL AGENCY USE ONLY <br />I <br />COUNTY # <br />m <br />OPTIONAL <br />JURISDICTION # <br />FACILITY It 00 79 <br />1 510 161 e= <br />E - OPTIONAL <br />'iT BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />'NER MUST FILE THIS FORL* THE LOCAL AGENCY IMPLEMENTING THE UNDERGROOTORAGE TANK REGULATIONS <br />