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• • wG�a..p,u �O <br /> STATE OF CALIFORNIA ` <br /> STATE WATER RESOURCES CONTROL BOARD a <br /> UNDERGROUND STORAGE TANK PERMIT APPCT o f <br /> COMPLETE THIS FORM FOR EAC AGILITY <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 21 T PERMANENTLY CLO <br /> ONE ITEM 2 INTERIM PERMIT d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5 Z.- <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> srl88 Tgnsc_� wc-AwaY a <br /> CITY NAME STATE ZIP CODE SITE PHONE M WITH AREA CODE <br /> —[{2 CAI/ BOX <br /> S-1(0 —� <br /> TO INDICATECORPORATION Q INDIVIDUAL IQ PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE AGENCY Q FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR 0 RESEIF INDIAN RVATION x OF TANKS AT SITE E.P.A. I..0..4(Opfimaq) <br /> O 3 FARM Q A PROCESSOR Q 5 OTHER OR TRUST LANDS 0 �' '�•'✓��1 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) 95 <br /> JI "!'It°>"1"1-lu ��� tz�aC 1 <br /> NIGHTS: NAME( T,FIRST) NE x WITH AREA CODE LN`IIG TS:NAM (LGi FIRST) q,Ka_-722—��CW <br /> PHONE#WITH AREA COOF <br /> II. PROPERTY OWNER INFORMATION (MUST BE COMPLETED <br /> NAME _ �^ � CARE OF ADDRESS INFORMATION <br /> MAUI1LIIN1NGOOLR/8TR'•E`E'T ADCO--RrEJSSCW <br /> �bo biWma Q INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY <br /> 911 L�1 ` CCORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITU NAME BT ZIPg�t P�tE a WITH AREA CODE <br /> LG�� �J'�]-700029 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 1\ <br /> MAILING OR STREET ADDRESS ✓ boa bugkals Q.INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a 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 CO PLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa biMkali, Q I SELF-INSURED 2 GUAMMEE Q 3 INSURANCE Q A SURETY BOND <br /> 0 5 LETTEROFCREDIT Q 6 EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is checked. <br /> WHICH CHECK ONE BOX INDICATING WH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER P TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT(AME(P^�WTED&&ySIGNNATTURREE) APPLICANT'S TITLE f DATE MONTTWOOOAYIYEAAR <br /> LOCAL A EN Y USE ONLY <br /> COUNTY p JURISDICTION p FACILITY F <br /> ® �NIVN3� d 11 117 <br /> LOCATION CODE -O TIO NAL CENSUS TRACT t -OPTIONAL SUPVISO=CODE -OPTIONAL <br /> THIS FORM 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) FOR0033A.5 <br />