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. teo ey I <br /> e C <br /> STATE OF CALIFORNIA + <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> �4,FOPNn <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY Q I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 50 <br /> I. FACILITY/31TE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA ORFACILITY AME NAME OF OPERATOR <br /> d N f C CPN6 ND <br /> NEARESTFROSS REET PARCEL#(OPTIONAU <br /> ADDRESS / <br /> /U��Ac c N <br /> TATE ZI CODE SITE PHONE#WITH AREA CODE <br /> CITY NAME CA � 952 <br /> —0260 <br /> ✓ <br /> SOX <br /> CORPORATION INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY (] FEOERA4AGENCY <br /> TO INDICATE DISTRICTS <br /> TYPE OF BUSIN SS O I GAS STATION 2 DISTRIBUTOR 0 ✓ IF INDIAN F#07 TANKS AT SITE E.P.A. I.D.#(oPlional) <br /> RESERVATION <br /> O 3 FARM Q 4 PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(FJST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME LAST,FIRSn PHONE%WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME N� <br /> In, ✓box binObale 0 INDIVIDUAL L] LOCAL-AGENCY O STATE-AGENCY <br /> MAILING OR STREET ADDRESS <br /> 0 CORPORATION PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY N ME /4/� <br /> N� �rI <br /> III. TANK WNER INFORMATI N-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OFO R <br /> ✓ box bIdbae INDIVIDUAL Q LOCAL-AGENCY 0 STATE AGENCY <br /> MAILING ORS REET ADDRESS <br /> CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> CIN NAME <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. <br /> TY(TK) 0 4 4 - 0 3 Z 6 <br /> V. PETRC LEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> 1 SELF INSURED0 UARANTEE 3 INSURANCE L--j 4 SURETY BOND <br /> ✓ box biMica 0 5 LETTER OF CREDIT 6 EXEMPTION 93 OTHER <br /> VI. LEGA NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II U hacked. <br /> CHECK ONE DX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.E II. 111.0 <br /> THI FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S <br /> THIDAYNEAR <br /> AME(PRINTED&SIGNATURE) <br /> APPLICANTS TITLE DATE MON <br /> LOCAL AGENCY USE ONLY <br /> [31 <br /> # JURISDICTION# FACILITY# <br /> �� (o {-1MTYZAno <br /> ELOCATIONDE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE .OPTIONAL <br /> q 23. 80 32-c— 2- /g'- c-Ff <br /> THIS FOi M 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) j//�C2 � � (� <br />