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co. e <br /> STATE Of CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �: <br /> 7 � COMPLETE THIS FORM FOR EACH FACILTIYISITE <br /> MARK ONLY 1 NEW PERMIT F73 RENEWAL PERMIT 5 CHANGE OF INFORMATION [:] 7 PERMANENTLY ^ D SITE <br /> ONE REM 2 INTERIM PERMIT IQ d AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION & ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME1 NAME OF PERATOR <br /> or IES C, r� n� rVcK-Z ZeIPI <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAU <br /> CITY NAME STATE Zip?DSI PHONE s WITH AREA CODE <br /> n CA /G INS 6r, 5 9- `aieb <br /> BOX TOINDICATE Q CORPORATION INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTV#GENCY Q STATE-AGENCY Q FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR �� O RE'/ IF INDIAN 1 <br /> SERVAT O <br /> OR TRUST LAN A OF TANKS AT SITE E.P.A. l D.t(goNUlap <br /> Q 3 FARM Q a PROCESSOR YJ 5 OTHER NDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) ONE t WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> c d2_,Vqsss-y 6Y <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE; WITH AREA <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME - <br /> OF ADDRESS INFORMATION <br /> 51 oe�ce a �o I(VC c j!!! 1, 14 n - �oC�c' <br /> MAILING STREET R S ✓ �xb Q INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> . a, <br /> ) 7-7 Q CORPORATION Q PARTNERSHIP Q COUNrYAGENCY QI FEDERALAGENCY <br /> CITY NA STATES ZIP 3 ` (FMONE HARE D�j� <br /> 0/1CC�� G <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Ooab Wicau Q INDIVIDUAL Q LOCAL AGENCY Q STATE AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q CDUNTYAGENCY Q FEDEPALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE t WITH AREA COOS <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323.9555 if questions arise. <br /> TY(TK) HQ 44 _F F-7777 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ �t bIMNW Q I SELNNSURED Q 2 GUARANTEE Q ] INSURANCE LQ 1 SURETY BOND <br /> 0 5 LmEROFCREDrr Q 6 EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent t0 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: 1.= II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JURISDICTION u ILITY x SHa-K C7C <br /> iT FT-F I 1 5 <br /> LOCATION CODE -OPTIONAL ( Z <br /> CENSUS TRACTS -OPTIONAL SUPV130?DISTRICT CODE -OPIn T �7 <br /> JSV ` <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(S91) FOR 5 <br /> 0(D 0 �Zv <br />