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s a' <br /> STATE OF CALIFORNIA .� colD <br /> STATE WATER RESOURCES CONTROL BOARD i��, v o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A = � „ <br /> �Nl,N4N N,N <br /> COMPLETE THIS FORM FOR EAC ACILITYISITE <br /> MARK ONLY Q 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHpNE#WITH AREA CODE / <br /> CA ��iy �F ld�r] ;A <br /> ✓ BOXCORPORATION 0 INDIVIDUAL O PARTNERSHIP =LOCAL-AGENCY = COUNTY-AGENCY = STATE-AGENCY = FEDERAL-AGENCY <br /> TO INgCATE DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION TRIBUTOR RESERVATION V 11 INDIAN #OF/TAJNKS AT SITE E.P.A. I.D.#(optimal) <br /> I= 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS (/ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME BAST,FIR �� PHONE#WIT =REAOCODE DAYS: Ngrv1E(LAST.FIRST) <br /> PHnNF&WITH AREA CODE <br /> NIGHTS: NAME(LAST.FI ST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE 9 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME C �! ,,.//a CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS f^Y ✓ box bindicate I1 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> =CORPORATION = PARTNERSHIP 0 COUNTYAGENCY [] FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE -# PHONEoHAREA CODE <br /> vr <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) `�C/ 7/vrGf`�i/C/i �/T/ <br /> NAME OF OW ER � . CARE OF ADDRESS INFORMATION <br /> MAILI GOR STREET ADDRESS ✓ bo NiNicaM � INDIVIDUAL = LOCAL-AGENCY =STATE-AGENCY <br /> CORPORATION = PARTNERSHIP = COUNTY AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATFj <br /> W7'_ PHO WI AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4-T4]- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate 1 SELF-INSURED =;.GUARANTEE = 3 INSURANCE =4 SURETY BOND <br /> = 5 LETTEROFCREDIT 6 EXEMPTION = S9 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.D II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 90 1 3, 5419 <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 />