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• i.e,.. c <br /> STATE OFCAUFORWA ` <br /> STATE WATER RESOURCES CONTROL SO ARO <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FOR'R A r f <br /> COMPLETE THIS FORM FOR EACHPI1CILrrYisiTE <br /> MARK ONLY 1 I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION u ] PEaMANETLY CLOSED—= <br /> ONE ITEM !_i 2 INTERIM PERMIT r s AMENDED PERMIT S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME r U` / _(� I NAME OF OPE.RATOS U <br /> f"j <br /> ADDRESS �.^1 /ILII-17� ^ NEARE;T CROSS STREET_ Y CELOPTIONAL) <br /> ir <br /> CITY NAME STATE ZIP CODE SITE PHONE A WITH AREA CODE <br /> Box <br /> TO INDICATE RATION Q INDIVIDUAL 'Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Q 1 GAS STATION Q 2 OISTRI3UTOR QI <br /> RESERVATION IF INDIAN <br /> a OF TANKS AT SITE E.P.A. I.D.a(OPIMal) <br /> 3 FARM Q A PROCESSCR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE+WITH AREA CODE = <br /> FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> u a WITH ARCAc <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING CR STREET ADDRESS = INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPoRATWN Q PARTNERSHIP Q COUNTYAGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA CAGE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS W.it mcm Q INDIVIDUAL Q LOCAL-AGENCY Q STATEAGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE t WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. <br /> TY(TK) HQ4 41- p Z 0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓�a cinOicaN Q I SELF-INSURED Q 2 GUARANTEE El 7 INSURANCE Q +SURETY 77, <br /> 0 5 tETTEROFCREOT Q A EXEMPTION Q 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.0 11.Q in. <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 b SIGNATURE) APPLICANTS TITLE DATE MONTW AYNEAR <br /> 9 2— <br /> LOCAL <br /> LOCAL AGENCY USE ONLY G✓ <br /> COUNTY a JURISDICTION n FACILITY At <br /> STi4�1/TZ10101112 1= <br /> LOCATION CO EE fOPTIONAL I CENSUS TRACT I .OPTIONAL SUPVISOR-DISTRICT CODE -OP77ONAL <br /> I _0 <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(5-911 F 2A 5 <br />