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0 `eOW C <br /> STATE OF CAUFORMA •�" <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A s; <br /> o Y� o <br /> COMPLETE THIS FORM FOR EACH FACILrrYISITE <br /> MARK ONLY LJ 1 NEW PERMIT F7 3 RENEWAL PERMIT F7 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM E 2 INTERIM PERMIT 0 4 AMENDED PERMIT E 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME I NAMEsO�F OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL N(OPTIONAL) <br /> &0?Sv Si rc►c l3l SGP L 14-, I <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Tv-f-c- CA 6'394v Box <br /> TOINDICATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION F7 2 DISTRIBUTOR0 ✓ IF INDIAN a OF TANKS AT SITE E.P.A. 1.D.$(optional) <br /> RESERVATION <br /> Gl 3 FARM Q 4 PROCESSOR 5�1 5 OTHER OR TRUST LANDS `L <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> ft� �., ►� sem, l�6 C5 2 -z <br /> NIGHTS: NAME(LAS'r,FIRST) PH NE N WITH AREA COOC NIGHTS: NAME(LAST,FIRST) <br /> R*V5 leza , r j?dq9- 1 119 PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME /� CARE OF ADDRESS INFORMATION <br /> C. .LDW/L.S;:_Xg0 <br /> MAILING OR STREET ADDRESS � ,V,(wt40)0 ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CYO O lI�Qu cew <br /> CITY NAME STATE ZIP O P ONE#WITH AREA <br /> PoCODE <br /> d efS*V7_,0•v C�¢ y56.6 S 1,2�•8 7 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME gg OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box btndicateINDIVIDUAL <br /> Q Q LOCAL-AGENCY Q STATE-AGENCY <br /> pO ezv CORPORATION PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL•AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> p'se�.6 .?5 V d - 878 <br /> IV.BOARD OF EOUA IZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate I SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q a SURETY BOND <br /> 5 LETTER OF CREDIT Q 6 EXEMPTION Q 99 OTHER <br /> A 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. it. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT ME(PRI IGNATURE) &.jerer 0V4CMW& PPUCANTS TITLE DATE MONTWDAYNEAR <br /> foe Rrrc ,tav ,E.V�/. C'coRb - <br /> LOCAL AGENCY USE 0 LY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT x -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 INFORMATION ONLY. <br /> FORM A(5.91) FOR0033A-5 <br />