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oop <br /> STATE OF CALIFORNIA 0 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FA (SITE �•��-°"�• <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT CHANGE OF INFORMATION � 7 PERMANENTLY CLOS <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT Ej 6 TEMPORARY SITE CLOSURE O/ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> n ✓co r✓.r 0-0 - C.-u c.....�L..a <br /> ADDRESS NEAREST CROSS STREET PARCELp(OPFIONAL) <br /> CITY INAME STATE ZIP CODE SITE PHONE It WITH AREA CODE <br /> u o4 CA 9S Zvr h/ y- Yrd G <br /> ✓ BOX <br /> TO INDICATE D CORPORATION 0 INDIVIDUAL O PARTNERSHIP O LOCAL AGENCY Q COUNTY-AGENCY O STATE AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION O 2 DISTRIBUTOR I = ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM O 4 PROCESSOR RESERVATION <br /> 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonal <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(L AST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,,FIRST) PHONE 9 WITH AREA CnOP <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bmbindkale INDIVIDUAL Q LOCAL-AGENCY O STATE AGENCY <br /> []CORPORATION D PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY <br /> CIN NAME $TATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS- ✓ box biMkale INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> ED CORPORATION PARTNERSHIP Q COUNTY-AGENCY I= FEDERAL-AGENCY <br /> CITU NAME' - STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF UA ON UST RAGE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO L4 <br /> V. PETROLEUM UST FINANCIAL (MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bin&ate [:1 1 SELF-INSURED L_j 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> =5 LETIER OF CREDIT =6 EXEMPTION (_f 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.❑ II.El III.O <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 TI TLE DATE MONTH/DAVNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# 1 FACILITY# <br /> 3 f 1 :L I7_1 lES71 5-,e o 2- <br /> LOCATION CODE OPTIONAL ICENSUS TRACT# --OPTIONAL SUPVISOR-DISTRICT 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 INFORMATIONY. <br /> FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 40 <br /> FOR0033A P6 <br />