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'e6OUR <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA =� At <br /> a <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> 1 MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT IfT-5—CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT E:] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESSNEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> CITE NAME STATE ZIP �^ J// JI EE <br /> "a" PHHOn E#WITH AREA COD <br /> CAS11 <br /> ✓ aox .'d "t1 <br /> TO INDICATE [ CORPORATION INDIVIDUAL (] PARTNERSHIP LOCAL-AGENCY <br /> DISTRICTS COUNTY•AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> TYPE OF BUSINESS 1 GAS STATION F—] 2 DISTRIBUTOR ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. I.—D.#(optional) <br /> 3 FARM O 4 PROCESSOR RESERVATION RESERVATION <br /> �1 OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHQNE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> ',A <br /> v <br /> NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) w)TH AREA_C. <br /> ONE#WITH AREA CnnF <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME <br /> - — <br /> � CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET—ADDRESS ✓ box bindicate [:l INDIVIDUAL LOCAL-AGENCY <br /> (] STATE•AGENCY <br /> ?I--CORPORATION [� PARTNERSHIP COUNTYAGENCYE FEDERAL-AGENCY <br /> CITY NAME <br /> r}-�' STATE� Zi�� PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-.(MUST BE COMPLETED) <br /> NAME OF OWNER f CARE OF ADDRESS INFORMATION <br /> A�TREE.TA Box IDmIcate = INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CITY NAME C/ �CORPORATION = PARTNERSWP Q COUNTY-AGENCY � FEDERAL-AGENCY <br /> 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 METHODS) USED <br /> ✓ box to indicate 1 SELF-INSURED [_:1 2 GUARANTEE Q 3 INSURANCE 0 d SURETY BOND <br /> C 5 LETTER OF CREDIT (]6 EXEMPTION 0 99 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 /> LCHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. IIL <br /> THIS FORM HAS BEEN COMPLETED TINDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATUAEp APPLICANTS TITLE DATE MONTHlDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> mT_ f l ,2 Gve_-�.L <br /> LOCATOR CODE -OPTIONAL CENSUS TRACTT#�-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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(5-91) <br /> FORp933A-5 <br /> i i <br />