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• 'V60V9 ff <br /> STATE OFCALIFORWA A� •• w <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> (ifO1,M• <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT El 5 CHANGE OF INFORMATION E:] 7 PERMANENTLY CLOSED <br /> ONE REM 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) 6i <br /> ORA OR FACILITY NAME <br /> pl l O NAME OF OPERATOR <br /> ADDRESS <br /> IZ� NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> E. o <br /> CITY NAME <br /> Lp FO�Q STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> BOX <br /> CA 9�Z37 7Z - Soo <br /> TO INDICATE I]CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY <br /> 'N owner of USTlea ublic agency,complete the lollwina:name of Su rvo/div0gDDISTRICTS• COUNTY-AGENCY' <br /> 0STATE AGENCYFEDE <br /> 19 161iRAL-AGENCY• <br /> Office Which opemtea the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(Optional) <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION !{ <br /> D OR TRUST LANDS �Ac 00 '7(762C> <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:!NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> ��W E I•� �i 7 Z 7—rjOp.Fj PHONE#WITH AREA CODE <br /> RE <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA OODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM k <br /> p�,_NI CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS p• p —7-7-5 ✓ boxbindicaw <br /> / INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> CITY NAME IED CORPORATION = PARTNERSHIP O COUNTYAGENCY O FEDERAL-AGENCY <br /> 1 D STATE ZIP CO E <br /> IFONE#WITH AREA CODE <br /> G' e--A 95g23� 2 jn7-45A� <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) Ssy <br /> NAME OF OWryER <br /> / /,p&'(✓T.l <br /> rI�I CARE OF ADDRESS INFORMgTION <br /> V /� <br /> MAILING OR STREET ADDRESS <br /> ✓ boa bindicaw INDIVIDUAL LOCAL 17-9-91 E. D /2DAgQ O STATE AGENCY <br /> CITY NAME _ 0 CORPORATION O PARTNERSHIP 0 COUNrY-AGENCY 0 FEDERAL-AGENCY <br /> G OG STA ZIP LADE PHONE#WITH AREA CODE <br /> 4�Z3 lFlxJ�Z�_ SCIS <br /> IV. BOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [4T4-]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boy biMkale 0 I SELF-INSURED 0 2 GUARANTEE 7 INSURANCE <br /> O 5 LETrER OFCREDIT I=6 EXEMPTION 0#SURETY BOND <br /> Q 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> 1.0 II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE <br /> DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# n <br /> FACILITY# � "f <br /> O D <br /> FLOCATIONOPTIONA CENSUSTRACT# -OPTIONAL17 <br /> SUPVISOR-DISTRICT CODE-OPipNAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESSTHS IS A CHANGE OF SITE INFORMATION ONLY, <br /> FORM A(393) OWNER MUST FILE THIS FORM WE LOCAL AGENCY IMPLEMENTING THE UNDERGROUvORAGE TANK REGULATIONS <br /> FORIXnaAflT <br />