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• <W^ [ <br /> STATE OF CALIFORWA • .° <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFA ILITY NAME NAME OF OPERATOR <br /> ADDRESS <br /> NEI EST CROSS STREET PARCEL MPPTIONAU <br /> CITY NAME STATE ZIP CODE ITE PCODE <br /> HONE s W ITH AREA <br /> Gv aoX — CA 9S$ Zoe 7Z7— -3 <br /> TO INDICATE 0 CORPORATION O INDIVIDUAL I]PARTNERSHIP O LOCAL'AGENCY 0 COUNTY-AGENCY' O STATE-AGENCY' <br /> DISTRICTS' O FEDERAL-AGENCY' <br /> N owner U UST Is a public agency,mnplete the fallowing:name of Supervisor of division,sembn,or office which operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN OF TAN <br /> Is KS AT SITE E.P.A. I.D.a(optimal) <br /> ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER I❑ RESERVATION <br /> IN OR TRUST LAUDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAM ( T,FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Z�J 7- SS3 <br /> NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> �. . Gri v <br /> MAILING OR STREET ADORES ✓ OosbintlkAle L-1 INDIVIDUAL D LOCAL-AGENCY 0 STATE AGENCY <br /> V LL E-1 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY <br /> CITY NAME AC FEDER4LAGENCY <br /> STATE ZIP CODE HONE A WITH AREA CODE <br /> c-4 95257 7Z-7 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> N70F OW R CARE OF ADDRESS INFORMATION <br /> v <br /> MAILING OR STREETADDRESS ✓ ..use.. INDIVIDUAL [71 LOCAL <br /> STATEAGENCY <br /> O CORPORATION O PARTNERSHIP 11 COUNTY-AGENCY 0 FEDERAL CITY NAME STAT ZIP CODE PHONE A WITH AREA CODE <br /> 9SZ3 ?p4�727-5�3 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bindbale Q I SELF-INSURED 0 2 GUMANTEE i.�7 INSURANCE <br /> O 5 LETTER OF CREDIT 6 EXEMPTION 99 OTHER O A SURETY BOND <br /> (] <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'V 11.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED d SIGNED) OWNER'S TITLE DATE MONTHIDAYtYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY• S iZ-- <br /> C�7 <br /> LOCATIONCODE -OPTIONAL CENSUSTgACT# .OPTIONAL SUPVISOR-DISTRICTOODE -OPRONAL <br /> Z3• G III 6 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFOPIATIOtif ON-Y. <br /> FORM A(31,S) OWNER MUST FILE THIS FORM WITH THE LOCA-AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 0 <br /> 0 <br /> FOROMMI <br />