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• • oue t <br /> STATE OF CALIFORNIA `� <br /> STATE WATER RESOURCES CONTROL BOARD w��, -, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �,n .>. � oe <br /> ��xlspPN�� <br /> COMPLETETHIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT D 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OPER <br /> 01 ATOR <br /> -� s �� trin�t�N <br /> ADDRESS NEAREST CROSS STREET AR <br /> ADDRESS <br /> °t 20 Cka <br /> Ave- <br /> CITY NAME STATE ZIP CODE TE PHONE#WITH ARE CODE <br /> on CA 9 5 �G6 'rj 59 - 231 Z <br /> ✓ BOX ORPORATION 0 INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY D COUNTYAGENCY 0 STATE-AGENCY D FEDERAL-AGENCY <br /> TOINDICATE DISTRICTS <br /> TYPE OF BUSINESS 0 t GAS STATION 2 DISTRIBUTORqE/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 4 PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) ONE#WITH AREA CODE DAYS: NAME(LAST,FIRST Z-0I S`lS—96 53 <br /> z09 57 -2312 er a4d <br /> NIGHTS: NAME(LAST,FIRST �Y HONE#WITH AREA CODE NIGH S: NAME(LAST,FI ST Z T <br /> P ONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRE S ✓ hox to Indicate O INDIVIDUAL LOCAL-AGENCY I� STATE-AGENCY <br /> D O & CORPORATION Q PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITU NAME 1 t ST? Z17C 3 / PL S#WITH AREA CODE� <br /> suy <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) 7 F� S � <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> �C 5 <br /> MAILING OR STREET ADDRESS ✓ box b indicate Ll'INDIVIDUAL LOCAL-AGENCY O STATE AGENCY <br /> CORPORATION O PARTNERSHIP COUNTYAGENCY 0 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 F4-[4-]- <br /> U z N g Z <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box b Indicate SELF-INSURED [-12 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> O 5 LETTER OF CREDIT O 6 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ it. It.O <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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# m 19 <br /> � 16)101116 gs <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL '/` / <br /> Q 3 2—& /' <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FORD033A-5 <br /> l�- A ',7 <br />