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-4, <br />STATE OF CALIFORNIA <br />/ STATE WATER RESOURCES CONTROL BOARD <br />Cl� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />ORM FOR EACH FA ITV/SITE-"��°""� <br />MARK ONLY 1 MIT O 3 RENEWAL PE IT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED�DE <br />ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �^(�j1' <br />I. F ITYISITE INFORMATION R Annnmcz - /AAI ICT OC nAA#n1 n� <br />D ORFACILITYNAME <br />r <br />CARE OF ADDRESS INFORMATION <br />N EOFOPERATOR <br />✓ box blldbat# D INDIVIDUAL O LDCAL-AGENCY STATE -AGENCY <br />CORPORATION 0 PARTNERSHIP (] COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />I/ 0 <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />ADDRESS <br />NE ESTCROSS STREET <br />PARCEL#(OF TX)NAU <br />/� <br />✓ bo>I bilbk INDIVIDUAL <br />LOCAL-AGENCY� STATEAGENCY <br />CITY NA E <br />J V <br />I•• <br />STA ZIP CODEC <br />SITE PHONE # WITH AREA CODE <br />STA12:',Wj <br />✓ BOX <br />PHONE #WITH AREA CODE <br />TOINDICATE <br />D CORPORATION INDIVIDUAL E-1 PARTNERSM <br />(] LOC .AGENCY 0 COUNTY -AGENCY Q <br />STATE -AGENCY 0 FEDERAL -AGENCY <br />D CTS <br />OF BUSINESS <br />O 1 GAS STATION 2 DISTRIBUTOR <br />✓ IF INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (Wmnae <br />= 3 FARM O 4 PROCESSOR O 5ER <br />RESERVATION <br />OR TRUST LANDS <br />cmcnucn 1 AUI PtnSDn P EMERGENCY CONTACT PERSON (SECONDARY) • optional <br />)AVS: NAME (LAST. FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) <br />TIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) <br />II. PROPERTY OWNER INFORMATION • IMIIRT RF rnMPI FTFn1 <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box blldbat# D INDIVIDUAL O LDCAL-AGENCY STATE -AGENCY <br />CORPORATION 0 PARTNERSHIP (] COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />III./iANK OWNER INFORMATION • fMUST RE COMPLETFDI \ <br />IV. tJUAUD OF EQUALIZATION UST STORAGE FEE ACCOUNTINUMBER,Call(9 6)323-9555 if questions arise. <br />TY (TK) H 4 4 AA%�V. PETROLEUM UST Fl RESPONSIBILITY • (MUST BE D) —IDENTIFY THE METHOD(S) USED <br />✓bow birMbale [–I I SELF INSURED 2 GUARANTEE [=1 3 INSURANCEM 0 4 SURETY BOND <br />= 5 LETTER OF CREDIT 6 EXEMPTION = W OTHER ,A`�lplll/ <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. O II. O III. <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE SEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />,PPLICANT'S NAME (PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br />y-z�-93 <br />LOCAL AGENCY USE ONLY _ <br />COUNTY # # ,T , � L RISDICTION # FACILITY # <br />9 <br />-OCATION CODE11TIONAL CEN�S T�1C1 j;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 INF013MATION ONLY <br />FORM A (12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />` FORM33A-R6 <br />V <br />CAREOF DRESS INFORMATION <br />tNAEWNER <br />ST ET ADDRS <br />ZV <br />/� <br />✓ bo>I bilbk INDIVIDUAL <br />LOCAL-AGENCY� STATEAGENCY <br />J V <br />I•• <br />CORPORATI 0 PARTNERSHIP <br />= COUNTY.AGENCY 0 FEDERAL -AGENCY <br />STA12:',Wj <br />CODE/ <br />PHONE #WITH AREA CODE <br />IV. tJUAUD OF EQUALIZATION UST STORAGE FEE ACCOUNTINUMBER,Call(9 6)323-9555 if questions arise. <br />TY (TK) H 4 4 AA%�V. PETROLEUM UST Fl RESPONSIBILITY • (MUST BE D) —IDENTIFY THE METHOD(S) USED <br />✓bow birMbale [–I I SELF INSURED 2 GUARANTEE [=1 3 INSURANCEM 0 4 SURETY BOND <br />= 5 LETTER OF CREDIT 6 EXEMPTION = W OTHER ,A`�lplll/ <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. O II. O III. <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE SEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />,PPLICANT'S NAME (PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br />y-z�-93 <br />LOCAL AGENCY USE ONLY _ <br />COUNTY # # ,T , � L RISDICTION # FACILITY # <br />9 <br />-OCATION CODE11TIONAL CEN�S T�1C1 j;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 INF013MATION ONLY <br />FORM A (12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />` FORM33A-R6 <br />V <br />