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yOJA f <br /> PE C <br /> P Oen <br /> STATE OF CALIFORNIA ;",�1 0 <br /> STATE WATER RESOURCES CONTROL BOARD w �, - u o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA ?e <br /> COMPLETETHIS FORM FOR EA H FACILITYISITE <br /> 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 1--] 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE O�/ <br /> IT <br /> ONE ITEM F—] 2 INTERIM PERMIT <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED)of OPERATOR <br /> DSAORFAC((ILITV NAME 40 QN <br /> QNTeC0. i�4 1� NEAflEST CROSS STREET PARCEL p(0PTI0NAL) <br /> AD RESS <br /> STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CITU NAME CA <br /> IJ <br /> TOINDI�CATE O CORPORATION INDIVIDUAL O PARTNERSHIP 0 LOCAL- GENCY 0 COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(eplional) <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR RESERVATION <br /> O 3 FARM O 4 PROCESSOR O S 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 /> WITH ARE6 CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME 11;l'- <br /> r �p ^//J/ <br /> Mot fv T {�77� / borbindIc 0 INDIVIDU 0 LO'ALAGENCY EDSTATE-AGENCY <br /> MAILINGOR STREETADDRESS n <br /> 0 CORPORATION 0 PARTNERSHIP 0 01- 0GENCY 0 FEDERAL-AGE <br /> NCY <br /> 6 S O W�^' STAT ZIP CODE PHONE'WI <br /> WITH AREA CODE <br /> CITY NA E <br /> ZIdro <br /> T777jaigi <br /> INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION✓ bontnindk 0 INDIVIDUAL 0 LOCA4AGENCV ID STATE-AGENCY <br /> RESS0 CORPORATION D PARTNERSHIP O COUNTY-AGENCY 0 FEDERALAGSTATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4-F4-1- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED 4 suRE YeDNo <br /> GUARANTEE O INSURANCE <br /> ✓ borbindica0 5 LETTER OF le O 1 SELF D EXEMPTION 0 99 OTHER <br /> ROFCCREDIT <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: <br /> I.0 11. Ill <br /> PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TAUS AND CORRECT <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> APPLICANT'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# <br /> JURISDICTION# FACILITY# <br /> - STRICT CO <br /> LOCATIONCODE -OPTIONAL US CENSTRACT# -OPTIONAL SUPVISORDIDE -OPTIONAL <br /> 2 S— <br /> q 23 .8o <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) \ <br /> �1 C\ y _I <br /> J e <br />