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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 1 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILrrY/SITE <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTL CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT O 4 AMENDED PERMIT 5 TEMPORARY SITE CLOSURE Z <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ✓✓ <br /> OBA OR FAC NAME NAME OF OPERATOR <br /> 7176&tn_51nA <br /> ADDRESS �T ,?L p NEAREST CROSS STREET PARCEL (OPTKMAW <br /> CITY NAML/�'• STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> - I/ BOX CA <br /> TOINDICATECORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> -TYPE OF BUSINESS Q 1 GAS STATION Q 2 DISTRIBUTORQ ✓ IF INDIAN sOF TANKbSITE E.P.A. I.D.#Taptloml) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•opTlonal <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME /r l COE OF ADDRESS INFORMATION <br /> MAILIN//�i�;R STREET AD/gRIESTS/��, ASL ✓ boa bllydlaro �rQ ONIDUAL Q LOCAL-AGENCY [I] STATE-AGENCY <br /> lL/7 <br /> AD ftl 1 kf Q CORPORATION [PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-ArENCY <br /> CITY Ntp1oCk� STATE ZIP CODE HONE x WITH AREA CODE <br /> l/l' I� 95205z 9 �O <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER �`^ ' CAREOF ADDRESS INFORMATION <br /> 1/-f.a� <br /> MAILING OR STREET ADDRESS ✓ boa biMkal9 Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTYAGENCV Q 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 3 2 2 2 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECOMPLETED)—IDENTIFY THEMETHOD(S) USED <br /> ✓ boa blMbaN Q 1 SELF-INSUREDQ GUARANTEE Q 3INSURANCE <br /> Q 4 SURETYBOND <br /> Q 5 LEITER OF CflEpT 6 EXEMPTION Q 93 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II' hecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ 11. III.CD <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> C�ODU�NTTYI�# (1 JURISDICTION# CILITY# <br /> LOCATION CODE OPTIONAL CENSUS TRACT ;OPj/pNAL SUPVISOR_DISTRICT CODE -OPTI <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B UNLESS THIS IS A CHANGE OF SITE INFORnTION NII <br /> FORM A(5-91) i FOR <br /> _\o G\ ft <br />