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�4 <br /> t 1� <br /> w S <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACHFACILITYISITE <br /> 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C <br /> ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT L5 3 <br /> =MANFLY ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> M ❑ 2 INTERIM PERMIT <br /> I. FACILITY/SITE INFORMATION&ADDRESS (MUST BE COMPLETN DE OF OPERATOR <br /> OBAORFACILITY E�rO ? PARCEL#(OPTIONAL) <br /> NEAREST CROSS STREET <br /> ADD SITE PHONES WITH AREA CAGE <br /> /Of <br /> ,. STATE 21P� <br /> CITY NAM CA <br /> LOCAL-AGENCY ED COUNTYdGENCV' C7 <br /> STATE-AGENCY' [] FEDEPA4AGENCY' <br /> ✓ BOX 0 CORPORATION 0 INDIVIDUAL O PARTNERSHIP C] DISTRCTS' <br /> TO INDICATE <br /> •II owner d UST Is a Public agency.oorrylele the lollowbB:narre d Supervisor d tlNlsbn,eadbn,or oX�ira whk�oper NDIAN #OF TANKS AT SITE E.P.A. I.D.#(apTlmel) <br /> ❑ 2 DISTRIBUTOR RESERVATION <br /> TYPEOFBUSINESS O❑ 3GFAARMTATION 4PROCESSOR 5OTHER ORTRUSTLANDS <br /> EMERGENCY CONTACT PERSON (SECONDARY)•O"'Onat <br /> EMERGENCY CONTACT PERSON (PRIMARY) DpyS: NAME(LAST.FIRST) PHONE s WITH AREA CODE <br /> E(LAST IRST) PHO DWITH AREAC �� <br /> DAV ' �L ,` 1'IL ` PHONE a WITH AREA CODE <br /> �(/T p NEe WI AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> NIGHTS: NAME(LAST, RST) <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED, CAREOF DDRE INFORMATIOA T+r <br /> NAME C I/ fv <br /> b M b C3 INDIVIDUAL LOCA AGENCY El STATE-AGENCY <br /> MAILING O STREET ADORE /A s O �] <br /> COR O PARTN�HIP 0 COUMYAGENCY 0 FEDERAL-AGENCY <br /> 3 p IJ L x S TE ZIP ODES PHONE a WITH AREA CODE <br /> CITY NA <br /> li- <br /> 111. TANK OWNER INFORMATION.(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> ✓ E-AGENCY <br /> box blydksN 0 INDIVIDUAL 0 LOCAUAGENDY OSTAT <br /> MAILING ORSTREETADDRESS L-.J CORPORATION 0 PARTNERSHIP 0 COUNTY AGENCY 0 FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Cal(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S)INSURANCE SED ED A SURETY BOND <br /> 0 I SELF INSURED O 2 GUARANTEE gy OTHER <br /> ✓OoxbWkete E-15 LETTEfl OF CREDIT 0 8 EXEMPTION <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'❑ <br /> IL ul. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IDSA UE ANDCORR CT <br /> OWNER'S TITLE <br /> OWNER'S NAME(PRINTED&SIGNED) <br /> LOCAL AGENCY USE ONLY FAC <br /> IILIITTYY0 /�� <br /> C�OOUTmNTY# JURISDICTION# Ly—Jcly229 <br /> "—' � 9UPLrISOR•DISTR CODE •OPTTOIW. <br /> LOCATIO�II .OPMONAL CENSUS TRACT#•OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS LS ACHANCE OF SITE INFOR TION OIfLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORORHi <br /> FORM APW) 0 <br /> • 1�l l CI1q�JB <br />