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• • STATE OF CALIFORNIA • • �i<4„ a, <br /> STATE WATER RESOURCES CONTROL BOARD • -a�yt'; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> •�•l•4M Y.• <br /> COMPLETE THIS FORM FOR EACH FACfLrTYISITE <br /> MARK ONLY LJ 1 NEW PERMIT F-13 RENEWAL PERMIT �5 CHANGE OF INFORMATION r 7 PERMANENTLY CLOSED SITE <br /> CNE ITEM 2 INTERIM PERMIT 6 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> OY/7 G/s7 u i <br /> ADDRESS NEAREST CROSS STREET PARCELO(OPTIONAU <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> TO INDI ATELJcr CORPo TION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDEPALAGENCY <br /> 06'TRK:TS <br /> ttPE OF BUSINESS RES <br /> 1 GAS STATION 0 2 DISTRIBUTOR Q _' IF INDIA OF TANK$AT SITE E.P.A. I.D.IT(FWimAQ <br /> ET A <br /> 0 7 FARM Q s PROCESSOR 0 5 OTHER OR TRUST LAN D <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGCTkONTACT PERSON (SECONDARY)•optlonal <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST "I T) <br /> G '.F I 7G/�6L viS- svS"- ? 76 « . z; k IV <br /> NIGHTS: NAME(LAST•FIRST) PHONE I WITH AREA CODE NIGHTS ME(LAST FIRST) <br /> S J PHCNF a WITH <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF RESS INFORMATION <br /> MAILING OR STREET ADDRESS % / bintlkab Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> / /tJ ,CG[ �i j / l{/ SU A,(P (f•s"(� C011PoMTION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME ATE ZIP CODE PHONE A WITH AREA CODE <br /> Lva/ of Cv�eE C» 70 <br /> III. TANK OWNER INFORMATION-(MUST B4 COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ wxbu m Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE I ZIP CODE PHONE t 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 0 3 d a- (o <br /> V. PETROLEUM UST FINANCIA�PONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ �a binmaan 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q A SURETY BOND <br /> Q S LETTEROFCREDT Q 5 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 /> CHECK ONE 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(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY p JURISDICTION a FACILITY a 7`f 61A)ION <br /> LOCATION CODE •OPTIONAL CENSUS TRACOPTIONAL SUPVISOR.DISTRICT CODE -OPTIONAL <br /> ©/ Ti 3,?7) _3-1 3 <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 /> FORK A(5-91) // FORMIA 5 <br />