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• 0 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i4F <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W <br /> g; <br /> ca, <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> M Y 1 NEW PERMIT 71 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION PERMANEN Y CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT F7 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME1 -ly_ � f" ^ p5 NAME OF OPERATOR <br /> ADDRESS � ,/�l tfj lqNEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> LtiWAI e� <br /> CITY NAME STAZIP §_ SITE PHONE M WITH ADE <br /> CA 147S-37 <br /> S-J7I/ Box <br /> i <br /> T01NOICATE C]CORPORATION 0 INOIVIOUAL 0J.PAERSHIP 0 LOCALCTSENCY 0 COUNTY-AGENCY C3 STATE-AGENCY 0 L <br /> FEDERAAGENCY <br /> DISTRI <br /> TYPE OF BUSINESS Q 1 GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN x OF TANKS AT SITE E.P.A. L D.x(optimal) <br /> RESERVATION <br /> 0 3 FARM Q 4 PROCESSOR 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 /> _ s%Z <br /> NIGHTS: AAAC(L T,FIRS HONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHQNP z WITH ARPA <br /> II, PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ W.CMI Q INDIVIDUAL (] LOCALAGENCY Q STATE AGENCY <br /> Q CORPcRATICN = PARTNERSHIP COUNTYAGENCY O FMERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Ooa P Q INONQUAL Q LOCAL-AGENCY STATE-AGENCY <br /> (]CORPORATION Q PARTNERSHIP COUNTY-AGENCY (] FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE S WITH AREA CODE <br /> IV. BOARD OF EOU IZATION UST STORAGE FEE A COUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO a -1013_17-1 <br /> 2 <br /> V. PETROLEUM U T FINANCIAL RESPONSIBILITY (MUST BE COMPL )—IDENTIFY THE METHOD(S) USED <br /> ✓ boa Vi kala Q 1 SELF-INSURED Q 'TEE =3 INSURANCE 0 a SURETY 90NO <br /> LETTER EXEMPnON 0 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: I.❑ II.= III. <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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR/ <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FA ITY# <br /> � R fA1I✓7 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTION <br /> Z 'L <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORMS,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) ,. FOROMA-5 <br />