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'OeOUn ( 00 <br /> STATE OF CALIFORNIA T �r �� <br /> STATE WATER RESOURCES CONTROL BOARD w��, ss a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A e <br /> �: o <br /> COMPLETE THIS FORM FOR EACH FACILrTYISITE <br /> MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENT CLO <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME ^ NAMEOFOPERATOR <br /> L: DT�� MI/ <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> U LOr/I S <br /> CITY NAME STATE ZIP CODE EPHONE#WI AREA CODE <br /> G ,B CA3,3o <br /> TOINDICATE CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNTY AGENCY F7STATE AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Q 1 GAS STATION2 DISTRIBUTOR = R / IF INDIANSERVATION #OF TANKS AT SITE E.P.A. 1.D.#(ap6ma# <br /> O 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) PHONE I;WITH AREA rnnF <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COTIP <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING ORSTREETAD ESS ✓ boa biMicale OINDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> L, "() . ORPORATION0 PARTNERSHIP 0 COUMYAGENCY 0 FEDERIUAGENCY <br /> CITY NAME S©/� ZIP GODS PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION- (MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> L; bb� n5 �o <br /> MAILING OR STREET AQDR S ^^'�� (`� .1boa thdi 0 INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> G—Cl I�CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERALAGENCY <br /> CITY NAME STAT ZIP CODE PHONEi WITH AREA CODE <br /> c ro S 33 0 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - $ $ 8 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓boa b Indicate 0 I SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> O 5 LETTEROFCREDIT O 6 EXEMPTION 0 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: I.O II.❑ III.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# Z/,68E SO <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DIST ICT CODE -OPTIONAL <br /> 3 z� a31>v <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(5-91) FORM33A 5 <br />