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i 1 ' <br /> E <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE t� ' <br /> - cel lFpp N.r <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION a 7 PERMANENTLY CL . ITE <br /> ONE ITEM 2 INTERIM PERMIT F7 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAMEJE3PERATCR <br /> ADD 'IESS NEARE;*a"SS_TR� <br /> TYN� T PARCEL#(OPTIONAL) <br /> CILI (P STATE ZIP SITE PHQNE#W�ITHAREA CODE <br /> � <br /> l <br /> ✓ BOX 0 CORPORATION D INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> If owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR 0 RESEIF INDIAN #OF TANKS AT SITE E.P.A. L D.#(optional) <br /> 0 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> (JAYP: NAME(LAST,FIRS-0 PHONE#WITH AREA COD DA S: NAME( ST,FIAT) HON WIT R ODE <br /> NI H7S: NAME(LAST,FIR T) � PHONE#�WN���CODE N�TSiNAME jLAST,F�t� � NE PHOA-RE�CODE, <br /> II. PROPERTY OWNER INFORMATION (MUST BE COMPLFTFO) `/-L(�\v�'/J` L✓-�2�( �[7[ <br /> NAME CARE OF ADDRESS INFORMATION <br /> M ING OR STREET VDIRESY ���- v1bcx to i:ca'z [�1NDIVIDUAL (� LOCAL-AGENCY a STATE-AGENCY <br /> A �CORPORATION Q PARTNERSHIP COUNTY-AGENCY a FEDERAL-AGENCY <br /> CITY NAME STA ZIP���� �'�7�—WIP 'AREA 0D <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NPMSOF OWNE CARE OF ADDRESS INFORMATION <br /> MAILING OR STF WEETDR S ✓ box to indicate INDIVIDUAL l� LOCAL-AGENCY (] STATE-AGENCY <br /> © 'T" ^ 0 CORPORATION Q PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY' <br /> ON E <br /> TFIAgEA <br /> CIIE 1 E ZIP,7 "J �J PH �ICNCI D (/�'�1ewi <br /> a <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4]4-]-1 1 1 1 1 1 1 <br /> V. <br /> 4- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate =.1.SELF-INSURED = 2 GUARANTEE 0 3 INSURANCE [:]4 SURETY BOND =5 LETTER OF CREDIT 0 6 EXEMPTION =7 STATE FUND <br /> Q 8 STATE FUND 8 CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM = 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: L= IL F'Y III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRI A ) t TANK OWNER'S TITLE DATE MONTHMAAYNEAR <br /> .� / t <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ED <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT L�(1)OR MORE PERMIT APPLICATION- FORM B,UNLESSIS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6-95) <br /> OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROLWTIORAGE TANK REGULATIONS <br />