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• 0 <br /> STATE OF CALIFORNIA i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH F YISITE <br /> MARK ONLY NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> CNE ITEM 2 INTERIM PERMIT C 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL$(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE N WITH AREACODE <br /> Box �R n ef2 29 CA Z523 ` - <br /> TOINDICATE CORPORATIO 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COuNrV-AGENCY <br /> DISTRICTS OSTATE-AGENCY 0 FEDERAL-AGENCY <br /> TYPE OF BUSINESS O S STATION Q 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#f.Wimall <br /> RESERVATION <br /> Ey 3 FARM 0 4 PROCESSOR Q 5 OTHER Ofl TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE / DAYS: NAME(LAST,FIRST) <br /> // <br /> NIGHTS: AME(LAST, IRST) PHO E N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUS BE E COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> S 4�u <br /> MAILING OR ST [ ✓ boa tWk.. NDIVNUAL a LOCAL-AGENCY 0 STATE-AGENCY <br /> 5/7j �7 O CORPORATION =1 PARTNERSHIP I3 COUNTY AGENCY C:I FEDERAL-AGENCY <br /> C NAMESTATE ZIP CODE PHONE N WITH AREA CODE <br /> 6e o'n C—�} 3 7 <br /> III. TANK 0 ATION=(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa biMkaw INDIVIDUAL 0 LOCAL-AGENCY <br /> 0 STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL AGENCY <br /> CITU NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4-T74 - <br /> 3 3 (P <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boabbtlkaN 0 1 SELF-INSURED 0 2 GUARANTEE 0 7�ANCE <br /> 0 5(ETTEROFCRED(T D e EXEMPTION OTHER' <br /> THER O d SURETY BOND <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or If 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 /> APPLICANTS NAM E IF R WTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY, EAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> � t Tm0y)- <br /> LOCATIONCODE -OPTIONAL CENSUS TRACTS 3 TONAL SUPVISOR-DISTRN;T CODE -/OP7iONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5.91) <br /> ���� FOR0077�A/5� <br />