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0 •STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ID <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY � I NEW PERMIT 3 RENEWAL PERMIT E 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT E] e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> 3AOLADDRESS N ARESTCROSSSTREET PARCEL#(OPTIONAL) <br /> U G S /J U ✓� <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> S ck I0.1 CA 0/ v 2 9 -9 y �a7 <br /> BOX <br /> TO INa TE D CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY L-1 COUNTY-AGENCY O STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR R SERVATION #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> = 3 FARM 0 PROCESSOR Elk 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 /> monk ,) 6erj <br /> NIGHTS: NAME(LAST,FIRSTI PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COT <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME L - CARE OF ADDRESS INFORMATION <br /> MAILING OR STR ET-It.S �ry1 /3/�_ ✓ boa bintlkal# I� INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> N a �f 2-0O TCL' v CORPORATION Q PARTNERSHIP O COuNTYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE21P CODE PHONE#WITH AREA CODE <br /> S1/-v c k-f-- n (aA qS 2v 2i <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa bindkaN D INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> =CORPORATION 0 PARTNERSHIP COUNTY AGENCY O FEDERALAGENCY <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 F4-F4]- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa bintlka0 O I SELF INSURED 0 2 GUARANTEE 3 INSURANCE Q a SURETY BOND <br /> O 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= IL[=] Ill. <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 TIRE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> al�] FI-1-1 I I 1.115-lffl4i <br /> LOCATIONCODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> U1 2 <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INION ONLY. <br /> FORMA(5-9/) 16 0 <br /> FORW0 5 <br />