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�'Ou es <br /> STATE OF CALIFORNIA ? <br /> STATE WATER RESOURCES CONTROL BOARD a ., <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <� �0 <br /> o <br /> CSI IF UN N,� <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL SED SITE <br /> ONE ITEM 1_7 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADD S b� NEA EST CROSS STREET PARCEL#(OPTIONAL) <br /> L <br /> CITY NAME STATE ZIP CODE ITE PHONE#WITH AREA CODE <br /> CA 9 a o 5 A o 3 J 3 le � <br /> ✓ BOX COR RATION F7 INDIVIDUAL = PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> TO INDICATE C <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR / IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY L ) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> IJr a4& NITH AREA CODE <br /> NIGHTS: NAME(LASOr,FIRST) PHME#WITWAREA CODE NIGHTS: NAME(LAST,FIRST) <br /> s - <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMM� / / CARE OF ADDRESS INFORMATION <br /> C`� `/1/ / <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY <br /> ` � STATE-AGENCY <br /> CORPORATION [] PARTNERSHIP COUNTY-AGENCY (� FEDERAL-AGENCY <br /> CI E STATE ZIP CODE PHONE#WITH AREA CODE <br /> pm r/9 <br /> 1 <br /> III. TANK OWNER INFOR ATION-(MUST BE COMPLETED) <br /> NAME OF OWNERi 1 0 1 1 CARE OF ADD ESS INFORMATION <br /> S he. 1 'P <br /> MAILI OR STREET ADDRESS 01 <br /> ✓ x tb indicate INDIVIDUAL OLOCAL-AGENCY STATE-AGENCY <br /> Qo CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE 1 ZIP CODE PHONE#WITH AREA CODE <br /> C <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ <br /> V. PETROLEUM UST FINAN%k RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 2 GUARANTEE E::] 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION 0 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: I.= II.0 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIO SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST B ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM ,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(5-91) /�_�` '1� � FOR0033A-5 <br />