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ebQurs e <br /> STATE OF CALIFORNIA ' <br /> STATE WATER RESOURCES CONTROL BOARD40 <br /> AL <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> '^ - COMPLETE THIS FORM FOR EACH F CILITYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> L FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> C G� fiA <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME �+ <br /> STATE ZIP CODE �) 2d`�PHONEITE -7 WITH AREA EA q]7_—Z-/ <br /> ✓ BOxCORPORATION �] INDIVIDUAL PARTNERSHIP ] LOCAL•AG€NCY COUNTY-AGENCY EDSTATE-AGENCYFEDERAL-AGENCY <br /> TO INDICATE DISTRICTS <br /> TYPE OF BUSINES E-1 1 GAS STATION 2 DISTRIBUTOR E:1 R SERVATIIOO #OF TANKS AT SITE E.P.A. D.#(optional) <br /> 3 FARM 0 4 PROCESSOR V6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRSTS PHO E#WITH <br /> �A7REA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> M7 ORSTREETADDRESS ✓ boxroindicate INDIVIDUAL [] LOCAL-AGENCY 0 STATE-AGENCY <br /> RATION (] PARTNERSHIP COUNTY=AGENCY E71FEDERAL-AGENCY <br /> NE# <br /> �p <br /> AME / 5 ATE ZIP CODE zOP13 7Z12 <br /> WITH ACODE <br /> �v� <br /> CITY <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to Indicate INDIVIDUAL 71 LOCAL-AGENCY L-1 STATE-AGENCY <br /> zq, �p 0 CORPORATICN 0 PARTNERSHIP 0 COUNTY-AGENCY Ell FEDERALAGENCY <br /> CITY NAME/ STAT ZIP C ONE# ITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boM to indicate 1 SELF-INSURED 2 GUARANTEE E:] 9 INSURANCE E 4 SURETY BOND <br /> LJ 5 LETrER OF CRFCIT 0 6 EXEMPTION 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.0 II.0 III. <br /> THIS FORM HAS BEEN COMPLETED CINDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY It <br /> Z <br /> 5�1 Ll I z 16 1�4t <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SU IS R-DISTRICT CODE -OPTIONAL <br /> THIS ORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FCaA-5 <br /> f <br />