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C6oum C <br /> r .uut. <br /> STATE Of CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD .,�� „p a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A , <br /> ac <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT Rr5 CHANGE OF INFORMATION [:] 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT 0 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FA N`A�E L NAME OF OPERATOR ` w <br /> ADDRESS IF NEARES CRO ITRE PARCEL (OPTIONAL) <br /> CITY NA STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> �., CA j — S-ZS-71SW <br /> ✓ IBXCORPORATION �INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCY' FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS' <br /> If owner of UST Is a public agen ,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR / <br /> IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> IF <br /> Q 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(OST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> s r 7Jg-- <br /> NITS: NAME(LAST,FI T) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> r' o - 6V- o <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMP ETEP <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS �+ ✓ ndicate = INDIVIDUAL = LOCAL-AGENCY (] STATE-AGENCY <br /> 1 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITT NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> S 3 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW S CARE OF ADDRESS INFORMATION <br /> d <br /> MAILIN R STREET ADDRESS 1 ✓ b ind cats INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> �r-- r. <br /> � L5 CORPORATION =PARTNERSHIP E::] COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATEZIP CODE PHONE#WITH AREA CODE <br /> .S Y-/O -/�37 - 8'S� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)3Z-9669 it questions arise. <br /> TY(TK) HQ4 4- -1011151716 „3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box ioindicate 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION (]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: 1.[] if.= III. <br /> ] <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYlYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> slil FM 10 10 111Z-1 7�I1I Ate 23, iy <br /> LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL SLIPVISOR-DISTRICT CODE-OPTIONAL <br /> k—� <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3/93) V\ 0 <br />