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• � ^BBOJv [9 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> id> . <br /> OSI iFOXM,O <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY t NEW PERMIT O 3 RENEWAL PERMIT CHANGE OF INFORMATION 0 T PER L <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FA ILITY NAME NAMEOFOPERATOR <br /> 1` Wo�lrs W1a.t its <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OWIONAW <br /> zzo pa �� <br /> CITU NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> a e,�ec1 CA q $336 <br /> ✓ BOX <br /> TOINDICATE O CORPORATION (] INDIVIDUAL l=PARTNERSHIP LOCAL-AGENCV E-1 COUNTY AGENCY O STATE-AGENCY 0 FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O t GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> Q 3 FARM O 4 PROCESSOR 5OOR RESERVATION TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonal <br /> DAYS:AAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> lw1 5� 23�f - N6 <br /> PHONE 9 WITH AREA Conp <br /> NIGHTS: NAME(LAST,FIRST3 PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONF 9 WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME n CAflE OF ADDRESS INFORMATION <br /> lel 0.h OS <br /> MAILING OR STREVT ADDRESS II \ ✓ boxWndkate INDIVIDUAL AL AGENCY 0 STATE-AGENCY <br /> no I V../ Ce et '}[/ x l=CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE ONE#WITH AREA CODE <br /> 95336 P20� z3g-ky6z <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> ,Sq M C S <br /> MAILING OR STREET ADDRESS ✓ box bindkala D INDIVIDUAL (] LOCAL-AGENCY 0 STATE AGENCY <br /> l�CORPORATION Q PARTNERSHIP 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 - `✓ (�-� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box blMlcale Ef�l SELF-INSURED O 2 GUARANTEE [-1 3 INSURANCE 0 4 SURETY BOND <br /> O 5 LETTEROFCREDIT O 6 EXEMPTION O SS 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.O III.❑ <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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIVEAR <br /> LOCAL AGENCY USE ONLY T <br /> COUNTY# '`,yrs` JURISDICTION# FFAACILIT�Y# T U L� Z2 <br /> d5l <br /> LOCATION CODE -OPTIONAL ICENSSTRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> z6 —/3.-�Z_ <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 /> FORMA(5-91) <br /> %�/ '0' <br /> 330.3 <br />