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�I �md <br /> STATE OF CALIFORNIA W <br /> STATE WATER RESOURCES CONTROL BOARD s <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> D <br /> COMPLETE THIS FORM FOR EAC CILITYISITE <br /> MARK ONLY 0 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE 6 <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAM OF OPERATOR <br /> i l4E pis <br /> ADDRESS / NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 16 <br /> CITY NAME STACTE ZIP CODE SITE PHONE#WITH AREA CODE <br /> o f�� A 4 ZED <br /> TOINq AC TE CORPORATION 0 INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL#GENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 1 STATION 2 DISTRIBUTOR RESV IF INDIAN <br /> ERVATION #OF TANK AT SITE E.P.A. I.D.#(optimal) <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME DAYS: NAME(LAST,FIRST) <br /> l G aa)7Z7- � <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMO{'3CARE OF ADDRESS INFORMATION <br /> �^ <br /> MAILIN OR STREETADDRESS ✓ boz aIWIt N O INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY <br /> /�� _ RPoRATION = PMTNERSHIPCOUNTY#GENCV E FEDERA4AGENCY <br /> 0 <br /> CITY NAME STATE ZIP CODE PHONE S WITH AREA CODE <br /> III.!/. TANK OWNER INFORMATION-(MUST BE COMPLETED) iy <br /> NAM OF OWNER CARE OF ADDRESS INFORMATION <br /> a <br /> MAILING OOR�REET�ADFD�_7ESS box blN"M Q INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> C 6/ / /�' s/IQ G ORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE , PHONE#WITH AREA CODE <br /> G6D.Z `��� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)3239555 if questions arise. <br /> TY(TK) HQ F4-1-4]- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY- (MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boz biMkNe 0 I SELF-INSURED 0 2 GUARANTEE lE] ] INSURANCE 4 SURETY BOND <br /> I=5 LETTER OF CREDT O 6 EXEMPTION O 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O 11.X <br /> III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND 6ORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> l L] vi6 <br /> LOC ION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 4?(51 -5. ZZ 1 3Z-0 P l <br /> THIS ORM 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) F-OR0077A5 <br /> //////�/� <br />