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STATE OF CALIFORNIA <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD f <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A 'gin <br /> COMPLETE THIS FORM FOR EACH FACILITYISTTE `'��•�•"'' <br /> MARK ONLY F--j 1 NEW PERMIT 3 RENEWAL PERMIT F—� 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT 0 4 AMENDED PERMIT [�] 6 TEMPORARY SITE CLOSURE 3 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME f NAME OF OPERATOR <br /> 67-itieY i <br /> ADDRESS NEAREST CROSSS REET PARCEL N(OPTIONAL) <br /> CITY NAME STATE ZIP CODE ITE PHONE#WITH AREA CODE <br /> Goy— CA 1lv BOX <br /> TOINDISTRICTS' <br /> DICATE (]CORPORATION �y INDIVIDUAL 0 PARTNERSHIP O LOCAL'AGENCY O COUNTY-AGENCY' ED STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> •H mner of UST Is a public agency,conplete the following:name of Supervisor of dlYsion,section,or office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR 0 gESEIF RVNMAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> GAYS: NAM (LAST.FIRST) PHONE#WIT^AREA G�E DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE 8 WITH AREA/CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> ��y aA4, aT <br /> MAILING OR STREET ADDRESS ✓ box blrAicaleINDIVIDUAL 0 LOCAL AGENCY 0 STATE AGENCY <br /> 3// (q/ - AJ�T ST 0 CORPORATION 11 PARTNERSHIP 0 COUNTY AGENCY 0 FEDERAL AGENCY <br /> CITY NAME STATE ZIPCODE <br /> [� HONE#WA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box lointlkateINDIVIDUAL E::] LOCAL AGENCY 0 STATE AGENCY <br /> �� OCORPORATION PARTNERSHIP O COUNTY D FEDERAL-AGENCY <br /> CITY N MESTATE ZIP CODE PHONE#WITH AREA CODE <br /> v,q Z 95.2.0 (Eva <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box birdicate 0 1 SELF INSURED 0 2 GUARANTEE 3 INSURANCE 0 4 SURETY 80No <br /> 0 5 LETTEROFCREDIT O 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.❑ 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&SIGNEDI OWNER'STrrUE DATE MONTWDAYYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 1-51 CIS 1'q 16 / s/ 4� / <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL 9UPVISOR.DISTRICT CODE -OPTIONAL Z4r <br /> /' <br /> � <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE NFORMAtION ONLY. <br /> OWNER MUST FILE THIS FORM W THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3931 � • FOR0033AI7 <br />