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e5o�aees <br /> STATE OF CALIFORNIA P �° <br /> STATE WATER RESOURCES CONTROL BOARD a_ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , <br /> COMPLETE THIS FORM FOR EACFACILITY/SITE <br /> MARK ONLY F__] 1 NEW PERMIT O 3 RENEWAL PERMIT EV5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 9V <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAQRFbileNAM©' I — 5+�� Tzym(n NAME OF OPERATOR <br /> ADDRESS nG NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 5D5 M&V Dr11/e. <br /> CITY N M STATE ZIP CQDEE SITE PHONE#WITH AREA CODE <br /> CA 05 <br /> ✓ BOX CORPORATION INDIVIDUAL = PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY (] STATE-AGENCY FEDERAL-AGENCY <br /> TO INDICATE DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR0 REV IF INDIAN SERVATION 144 OF TANKS AT7SITEE.P.A. I.D.#(optional) <br /> 3 FARM 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 /> PHONE*WITH AREA rODF <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY <br /> STATE-AGENCY <br /> =CORPORATION Ejj PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH 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 -I 0 I 0 I 0 I�I 0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 0 2 GUARANTEE (] 3 INSURANCE E__]4 SURETY BOND <br /> O 5 LETTER OF CREDIT (]6 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: I.❑ II.[—] It. <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 8 SIGNATURE) APPLICANT'S TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY /���I///��1�/n/ <br /> COUNTY# (�v' • rJURISDICTION# FACILITY# J <br /> all3 <br /> �p�-LTT- - <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#:OPTIONAL SUPVISOR-DISTRICT ODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFO MATION ONLY. <br /> FORM A(5-91) /f� Y FOR0033A-5 <br />