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• $OUR e <br /> STATE OF CALIFORNIA .. ......Pc° <br /> 9 <br /> f� STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA �Y� o' <br /> a <br /> •C�(IfOR N.♦ <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F_� 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL SED SITE <br /> ONE ITEM 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 NAM OF OPIfRATOR <br /> �a 4 S C -# C VA CLA,N 1-11 <br /> ADDRESSNEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> Vto a1.► <br /> CITY NAME STATE ZIP CODESITE PHONE#WITH AREA CODE <br /> r4 lee CA <br /> ✓ BOX PORATION 0 INDIVIDUAL I� PARTNERSHIP (� LOCAL-AGENCY [] COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> TO INDICATE DISTRICTS <br /> TYPE OF BUSINESS AS STATION = 2 DISTRIBUTOR / IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> 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,F1 SST) 1 PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> rou i� IG �vK✓) ZJ �2y('/� <br /> NIGHTS.'-+"E(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME /dAf f�9 CARE OF ADDRESS INFORMATION, a a <br /> MAILING OR STREET ADDRESS ✓ box Io indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> (-Sox Z CORPORATION [] PARTNERSHIP [] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CO b PHONE#WITH AREA CODE <br /> 533 <br /> WII. ANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> OF OWNER CARE OF ADDRESS INFORMATION <br /> L <br /> MAILING OR STREET ADDRESS ✓box to Indicate INDIVIDUAL 0 LOCAL-AGENCY (]STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY E::] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 -I b Z 1111 :6 0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 0 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> D 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 b or II is check <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. III.Ej <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CO <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# F AA,#j( Z y <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -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 SIT R TION ONLY. <br /> FORM A(5-91) FOR0033A-5 <br />