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J • tr, Ja <br /> STATEOFCAUFORNIA <br /> II�Yy STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH F ITYISITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 8 ADDRESS-(MUST BE COMPLETED) <br /> DBA O FACILITY NAME r &122 <br /> �� NAM F OPERATOR <br /> ADDRESS vl v <br /> 47512 <br /> 47S2 Z NEAREST CRO STREET PARCEL a(OPrONAL) <br /> CITU NAME STATE ZIP CODE <br /> �' 31 PHOLJ7;1 WITH A��CggE <br /> ✓ sox CA ?"VEW-7 <br /> TOINDICATE 0 CORPORATION INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' STATE-AGENCY'DISTRICTS' O FEDERAL-AGENCY <br /> 'Ii saner d UST le a public agency,ampige the following:name of Supervbor q dNbbn bn,or office which <br /> operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR O ✓ IF INDIAN AOF TgNKS AT SITE E.P.A. I.D.a('"Acral) <br /> Q 3 FARM 4 PROCESSOR 6 OTHER RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: N E(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> .L /O/� PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE WITH AflEA CODE NIGHTS: NAME(LAST,FIflST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMAT <br /> IO"w' <br /> MAILIN OR STREETADDRE ✓box bNgbale <br /> INDIVIDUAL O LOCAL-0.GENCY D STATE-AGENCY <br /> CITY NAMA .—__- O CORPORATION D PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) J�w.1.Lo <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bDXbindk— O INDIVIDUAL <br /> D LOCAL-AGENCY El STATE AGENCY <br /> CITY NAME -- -- D CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY D FEDERAL-AGENCY <br /> STATE ZIP CODE PHONEa WITH AREA CODE <br /> IV. <br /> TY(TK) HQ 4 4- -BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boxblydkale 0 1 SELF-INSURED O 2 GUARANTEE 3INSURANCE <br /> 0 BB OTHER <br /> 5 LETTER OF CREDIT O 6 EXEMPTION O A SURETYBONG <br /> O <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is ch d. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> I•0 II,Fr, <br /> III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTEDB SIGNED) OWNEBS TITLE =DATE LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# ,�FACILLITTY• [; <br /> LOCATION CODE -OPTIONAL CENSUS TRACT R -OPTIONAL ® SUPVISOR-DISTRICT CODE -OPTVI— <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMITAPPLICATION- FORM B,UNLESS THIS LS A CHANGE OF SITE INFORMATION NLY. <br /> FORMA(a,93) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> • • Fgi30730..R7 <br />