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0 0 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH F ILITYISITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ a RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PE ANENTLY LOSE SITE <br /> ONE ITEM 1:12 INTERIM PERMIT F-14 AMENDED PERMIT CD6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CR SS ST EET PARCEL#(OFTIONALI <br /> I `7-7-7 �✓, l�N�e eA� <br /> CITY NAME STATE CZIP CODE _ SITE PHONE A WITFJ AFEA Cy� <br /> A <br /> TO <br /> I/ BOX <br /> CORPORATION Q INDIVIDUAL Q PARTN RSHP Q LOCAL-AGENCY Q COUNTYAGENCY Q STATE-AGENCY Q FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ I S STATION ❑ 2 DISTRIBUTOR Q ✓ IF INDIAN A OF TANKS AT SITE E.P.A. L 0.A(WI mW) <br /> RESERVATION <br /> 7 FARM Q A PROCESSOR Q 5 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 /> NIG S: NAME(LAST,FIR PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> P40NF <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME 0 , 6AA' dL- 60 ue la m CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADORES V ✓ Eev o'ukkau 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 PHO^^ 1T_A � <br /> III. TANK OWNER INFORMATION-(MUST BE COMPL TED) __e <br /> /GJ <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓m.olmic" Q INOIVIOUAL Q LOCAL-AGENCY Q STATE AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FECERAL.AGENCY <br /> CITY NAME STATE ZIP CODE PHONE s 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- e)(�T �-AAp 000155 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFYTHEMETHODS) USED <br /> ✓Lm n Wkau Q I SELF-INSURED Q 2 GUARANTEE 7 URANCE Q4 SURETY a0NO <br /> Q 5 LETTEROFCREDIT Q S EXEMPTION 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: 1.E—] II.Go/ III.Q <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED 6 SIGNATURE) APPLICANTS TITLE DATE MCNTHIOAYNEAAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY» JURISDICTION p ILITY x <br /> 2f2`� � <br /> LOCATION CODE -OPT NAL ICENSU;jTTA2�OP7x7NAL SUPVISOR•DISTRICT CODE -OP <br /> v <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5.91) • 40 FOR0033A•5 <br /> ,moi �? <br />