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z5o�aeQs <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> ���, Cil�Fxi P t,•T <br /> r COMPLETE THIS FORM FORE CH FACILCTYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT It5 CHANGE OF INFORMATION n 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT �_� d AMENDED PERMIT6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> '::�'G ::T--!2:1 <br /> ADDRESS NEARAT DROSS STREET PARCEL#(OPTIONALy <br /> CITY NA'YI IE STATE ZIP CODE 1 TEP ANE WITH AREA 119 <br /> y_ �/^ I CA .a f . <br /> I � �J -J �y 7 <br /> ✓ BOX ��,,r <br /> TO INDICATE �LORPORATION INDIVIDUAL ] PARTNERSHIP LOCAL-AGENCY ] COUNITY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS C 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.O.#(optional) <br /> 3 FARM 4 PROCESSOR � OR 5 OTHER RESERVATON I <br /> TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WIJ.A AREA CODE DAYST NAME(LAST,FIRST) <br /> A( - <br /> PHONE g WITH AREA GODS__ <br /> NIGHTS: NAME(LAST,FIRST) P NE#WI``TH AR/E'A CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONEA-WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME ) f CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS �T^ ✓ box bindlcate = INDIVIDUAL LLOCAL-AGENCY [] STATE-AGENCY <br /> /✓��T `j CORPORATION = PARTNERSHIP [� CCUNTY-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 A II7�KESS• ✓ box toindicate indi <br /> - ] INDIVIDUAL � LOCAL-AGENCY [7 STATE-AGENCY <br /> ,�C4RPOHATICN I] PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERALAGENCY <br /> CITY NAME' STATE ZIP CODEPHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise, <br /> f _ _11 f <br /> TY(TK) HQ ,4.14 �- _ I 1— J � <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED [�] 2 GUARANTEE [] 3 INSURANCE L 4 SURETY BOND <br /> ]I 5 LETTER OFCRFDIT I] 6 EXEMPTION ] 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal noiificaiion and billing Will be sent to the tank owner unless box I or II is Checked. <br /> CHECK ONE BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L F—] IL U III. <br /> THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PR MTED&SIGNATURE) APPLICANT'S TITLE DATE MONTHIDAY1YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> I —LL r <br /> LOCATION CODE OPTIONAL (CENSUS TRACT* .OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 7 r fa <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 /> FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> • FOR4037A-R6 <br />