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• eoN <br /> STATE OF CALIFORNIA • ,.° pc' c <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A ��, <br /> ryr . <br /> C\<�fO,�N�\ <br /> COMPLETE THIS FORM FOR EA FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ # AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DB O FoACIL TY NAME NAM O OPErnRATOR <br /> r 1t of <br /> 6evlli v <br /> ADSS� NEAREST CROSS STREET PARCEL#IOPTIONAu <br /> CITVEWI / ��b rim�— <br /> STATE 21P COyfSITE PHONEM WITH AREfj CO <br /> CA Ub <br /> ✓ BOX <br /> TO INDICATE ORPORATION D INDIVIDUAL O PARTNERSHIP D LOCAL-AGENCY O COUNTY-AGENCY D STATE-AGENCY D FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN #OF TAN SAT SITE E.P.A. I.D.#(aplianap <br /> 3 FARM d PROCESSOR 5 OTHER RESERVATION U <br /> ❑ ❑ OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) ITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA Coop <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME ,brinn �� R S <br /> OF A S MATION <br /> M ILN R TRE ET ADDRESS ad Intlbate INDIVIDUAL D LOCAL-AGENCY D STATE-AGENCY <br /> VS CORPORA ON PARTNERSHIP I� COUNTY-AGENCY FEDERAL-AGENCY <br /> CI A E STATE ZIP COGF„//�/ ^D� PH NE%WITH AREA CODE <br /> III, INFORMATION-(MUST BE COMPLETED) P <br /> I �IItJ� NAMEIDNER &n� CARE OF ADDRESS INFORMATION <br /> UM V /�N'F✓✓•/� MAI ORSTREET RESS /—' ✓ 0indicate D INDIVIDUAL <br /> ✓l LOCAL-AGENCYD STATE-AGENCY <br /> P <br /> D RE / CORPORATION D PARTNERSHIP D COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITf NAM I ' STATES ZIP COD ��� PtIONE#WITH AREA CODE-�� <br /> Lj <br /> IV. BOARD OF L/EQUALIZ�A,TI�O�N UST <br /> /STORAGE FEE ACCOUNT NUMBER I-Call(916)323-9555 if questions arise. <br /> /Zl 6 J`Il <br /> TY(TK) HO F4-F4-1- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE CO LETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Sox b indicate L] I SELF INSUREDD GUARANTEE E-13 INSURANCE D C SURETY BOND <br /> D 5 LETTER OF CREDIT 6 EXEMPTION D 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.❑ II.❑ III. <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 TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> MOR 30 21liz 3 Z�l y2 <br /> LOCATION CODE - TIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DIS71 CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION• FORM BI UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOADD33A 5 <br /> 0 &__� L) <br />