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• • eoua <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> oroo <br /> COMPLETE THIS FORM FOR EACH F ILITYISITE <br /> MARK ONLY � 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O T PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE (o L <br /> I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME / / NAME OF OPERATOR <br /> O/ r <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> #� vn CAv BX <br /> TO INDICATE CORPORATION [71 INDIVIDUAL = PARTNERSHIP O LOCAL-AGENCY E:l COUNTY-AGENCY STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 I GAS STATION = 2 DISTRIBUTOR0 */ IF INDIAN 1101 TANKS AT SITE E.P.A. I.D.#Iuplimal/ <br /> RESERVATION <br /> 0 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> //o/w e n a Tv ti n G/G - S-3/- f yS Y <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIST) <br /> PHONE#WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 11?,1L <br /> yl <br /> MAILING OR STREET ADDRESS ✓box 0Indicate INDIVIDUAL AL-AGENCY <br /> STATE-AGENCY <br /> 02-1 5 , Ve r w (]CORPORATION (] PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> L' 9- 7f 3- Ce <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Su'� Rs ."' <br /> MAILING OR STREET ADDRESS ✓box IoWicate Q INDIVIDUAL O LOCAL-AGENCY STATE AGENCY <br /> Q CORPORATION = PARTNERSHIP Q COUNTY AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ box Io 01cate I SELF-INSURED 0 2 RANTEE 0 3 INSURANCE [:14 SURETY BONG <br /> 5 LErrEROFCREDT EXEMPTION W 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PR INTED&SIGNATU RE) APPLICANTS TITLE DATE MONTWDAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION k CILI�N# <br /> Jam/ -1-I 1 lie=r <br /> LOCATION CODE�PTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT C -OPTIONAL <br /> o� y <br /> THIS FORM MUST BE ACCOMPANIED BY AT (1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FORDUMA-5 <br /> Q ` X61 <br />