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STATE OF CALIFORNIA `- <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> V n•oy' <br /> COMPLETETHIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ S RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P ANE ED S7T <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> / Y <br /> ADDRESS L NEAREST;FPO53 STREET ASTATEAGENCY <br /> CITU NAME STATE <br /> ZIPCODE/ / AOpO/� <br /> TO BOX <br /> OXTE Q CORPORATION Q INDIVIDUAL []PARTNERSHIP Q LOCALDISTRI-AGENCY Q COUNTYAGENCY Q FEDEERR66AGENCYTYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR J INDIAN Y OF TANKS AT SITEma!) <br /> ❑ ❑ Q RESERVATION <br /> Q S FARM Q ! PROCESSOR Q S OTHER OR TRUST LANOS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS:NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS:NAME(LAST.FIRST) <br /> PHONEs WITH ARC A COOP <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME 01 ,71 T, /L CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ E°t bmkit. Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> t 0 D � Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEOERALAGENCV <br /> CITY NAME STATE ZIP CODS n PHONE 4 AREA CODE <br /> 777 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) L Cl 3 5 <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS I ✓ tloabiaakau Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. <br /> TY(TK) HQ 4 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa b WkA Q 1 SELF-INSURED Q 2 GUARANTEE Q 9 INSURANCE Q A SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 5 EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or IL's the d. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND SILLWG: I.❑ II. IN.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY u Q.f��' JURISDICTION 0 FACILITY x -1 2 <br /> - <br /> /� 1 <br /> LOCATION CODE -OP NA (CENSUS TPACTa •OP7(ONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST ST(1)OR MORE PERMIT APPLICATION- FORM S,UNLESSIS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5.91) FCROo11Ah <br />