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• 'W60;wC( <br /> • STATEOFCALIIR R"'A iy�, .' • , 'uy,g <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION, FORM A <br /> ACINGE OF E <br /> COMPLETE THIS FORM FOR EACB CHANGE OF INFORMATION El <br /> 7 PERMANENTLY CLOSED SITE <br /> 3 RENEWAL PERMIT <br /> 1 NEW PERMIT � e TEMPORARY SITE CLOSURE <br /> MARK ONLYCD4 AMENDED PERMIT <br /> 2 INTERIM PERMIT <br /> ONE ITEM MUST BE COMPLETED) <br /> NAME OF OPERATOR <br /> I. FACILITYISITE INFORM��m ADDRESS FARCELa10PTIONAL) <br /> DBA /IL!Va�/I O / NEAREST CROSS STREET <br /> r)2 C PI D r SITE PHONE#WITH AREA CODE <br /> ADDRESS/ / STATE Zip GO E/n O� <br /> (1 [J. CN ✓G STATE-AGENCY al)FEDERAL ENCY <br /> NCV <br /> CITY NAM COUNTY-AGENCY <br /> CD INDIVIDUAL 0 DISTRICTS ,/ IF INDIAN A OF 7ANI <br /> PARTNERSHIP Q Lp RICTS <br /> AT SITE E.P.A. I. (0plianal) <br /> BOX Q CORPORATION � <br /> TO INDICATE RESERVATION <br /> � 2 011TRIBUT00. S OTHER 0 TRUST LANOS O 110nal <br /> TYPE OF BUSINESS � ?FAgMTATION a 4 PROCESSOR � (SECONDARY)• P <br /> EMERGENCY CONTACT PERSON <br /> EMERGENCY CONTACT PERSON (PRIMARY) DAYS: NAME(LAST.FIRST) <br /> PHONE A WITH AREA CODE <br /> DAYS: NAME(LAST.FIRST) NIGHTS: NAME(LAST.FIRST) <br /> PHONE#WITH AREA CODE <br /> NIGHTS: NAME(UST.FIRST) <br /> MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> II. PROPERTY OWNER INFORMATION IVIDUAL LOCAL-AG QSTATE-AGENCY <br /> NAME V beablNkau 0IPDNERSHIP 0 COUNTY'AGENCY (� FEDERAL-AGENCY <br /> 0 CORPORATION PHONE#WITH AREA CODE <br /> 41LING O0.STREET ADDRESS STATE ZIP CODE <br /> CITY NAME <br /> MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> 111. TANK OWNER INFORMATION ( LpCALAGENCY CD STATE-AGENCY <br /> NAME OF OWNER "MiNkaw INDIVIDUAL FEDERAL-AGENCY <br /> ED CORPORATION C] PARTNERSHIP ED COUNTY-AGENCY <br /> MAILING OR STREET ADDRESS STATE <br /> ZIP CODE PHONE A WITH AREA CODE <br /> CITY NAME <br /> UST STORAGE FEE ACCOUNT NUMBER•Call(916)323.9555 ii questions arise. <br /> IV.BOARD OF EQUALIZATION <br /> TY(TK) HO 4 4 - O ZIDENTIFY THE METHOD(S) USED <br /> MUST BE COMPLETED)— suaE Y oND <br /> Q 7 w3URANCE <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY• 0 UARANTEE 0 OTHER <br /> Q 1 SELF-INSURED fi EXEMPTION <br /> Ooab Ndkala Q 5 LETTER OF CREDIT <br /> Legal notification and billing will be sent to the tankowner unless box Il of 11 is checked' <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> L� <br /> AND TO THE BEST OF MY <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED KNOWLEDGE•IS TRUE AND CORRECT <br /> FOR LEGAL NOTIFICATIONS AND BILLING: <br /> DATE MONTWDAVNEAR <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY-- —ERJU APPLICANT'S TITLE <br /> APPLICANT'S NAME(PRWTED 6 SIGNATURE) <br /> LOCAL AGENCY USE ONLY FACILITY# <br /> JURISDICTION# <br /> COUNTY# FT I ^` I <br /> �/IVFrS Z� `J �J SUPVIS4R-DISTR�T OPTIONAL VVv <br /> CENSUS TRACT TlONAL ,"/JZ3 <br /> LOCATION CODE -OPTIONAL /J 2 ,�O ON FOR <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR�7 MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SRE INFORMATION O/NI <br /> FORM A(5-91) 6 /'�1�� � • <br />