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\ • � f660Ve t <br /> f <br /> STATE OF CAUFORNIA o <br /> STATE WATER RESOURCES CONTROL BOARD W�� i 8 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A '6 <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE t-"'°""�f' <br /> MARK ONLY i NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLO_ 3 <br /> ONE REM 2 INTERIM PERMIT Q 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> n aOR FACILITY NP E NAME OF OPERATOR 1 <br /> C <br /> DDRESS NEAREST ROSfSTREET V V PARCEIs(OPf ONAU <br /> CITU NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> ca 5a - 0 vgsaa 9`t`,- 5 <br /> ✓ POx CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE O DISTRICTS' C4i <br /> 'If owner of UST Is a public agency,mnplele the following:name of Supervisor of division,section,or onice which operates the UST <br /> 2 DISTRIBUTOR Q /ER <br /> IF INDIAN #OF TANKS AT E E.P.A. I.D.#(apllmal) <br /> RES <br /> TYPE OF BUSINESS 1 GAS STATIONVATION <br /> Q 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional - <br /> DAVS: NAME(LAST,FIRST) PHONE#WITHAREACODE DAYS: AME <br /> (LAST.FIRST) PHONE#WITH AREA CODE <br /> �I^ aD <br /> PHONE#WITH AREA CODE NIGHTS: NAME ,FIRST) PHONE#WITH AREACOOE <br /> NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME _:Y0 &P, /r'Ai ,C Q l0 0 <br /> MAILINGOR STREET ADDRESS ✓ boxbindkste = INDIVIDUAL =LOCAL-AGENCY TATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERALAGENCY <br /> -- __—_ STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Doxb Wkale O INDIVIDUAL 0 LOCAL STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HO ` L4+ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> 1 SELF-INSURED O 2 GUARANTEE O 3 INSURANCE O 4 SURETY BOND <br /> ✓ box birdkale0 0 ss OTHER <br /> 5 LETTER OF CREDIT 6 EXEMPTION <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.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAM E(PRINTED&S IGNED) OWNER'STFTLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY c, Z b a 31 l0 9 <br /> COUNTY# JURISDICTION# err------' FACILITY <br /> LIv <br /> Y// I <br /> LOCATION CODE -OPTIONAL CENSUS TRACTi •OP NAL 9UPVISOR-DISTRICT CODE •OP7TONAL <br /> 3 , 5 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR003M0 <br /> FORMA(393) <br />