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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ,[p <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'"Fort"', <br /> MARK ONLY X1 NEW PERMIT 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM [:] 2 INTERIM PERMIT 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 /> lsqea� Gr T,Wilen rl=1N 01 Z, PCOS!f <br /> ADDRESS NEAREST CROSS STREET PARCEL <br /> CITY NAME STATE ZIP E SITE PHONE#WITH AREA CODE <br /> r ev Ca 3 ke 2 .s-qq-41s- <br /> ✓ Box CORPORATION INDIVIDUAL PARTNERSHIP 'LOCAL-AGENCY ED COUNTY-AGENCY' 0 STATE-AGENCY' =FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS' <br /> H 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 t GAS STATION 2 DISTRIBUTOR O REBEIF R INDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.#(aptional) <br /> 3 FARM O 4 PROCESSOR = 5 OTHER OR TRUST LANDS Z <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST) PH,O�NEE#WITH AREA CODE DAYS:NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> R11 AL1 5 T.B--g° y <br /> S: NAME(LAST,FI T) HONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> _NIGHTII. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME // CARE OF ADDRESS INFORMATION <br /> c— <br /> MAILING OR STREET ADDRESS ✓box b In,lksta <br /> INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> ®� -` �` EKOORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE'- ZIP CODE PHONE#WITH AREA CODE <br /> �S s10 - h, 9'- <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box windicate INDIVIDUAL D LOCAL-AGENCY STATE-AGENCY <br /> � e <br /> �® CORPORATION Q PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CI .NAME STA ZIP CODE HONE WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST <br /> STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> 011 011 1 71 71 <br /> HYNQ3 <br /> V. PETROLEUM-UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bindicateSELF-INSURED =2 GUARANTEE Q 3 INSURANCE 0 4 SURETY BOND <br /> 5 LETTEROFCREDIT 0 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: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED 8 SIGNED) OWNER'S TITLE 1 DATE M TH/DAYNEA <br /> B'1 C <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OIPTTONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE ffORMATION ONLY. <br /> OWNER MUST'FILE THIS FORM W11'�i`THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMA(3ra3) <br /> t F3A4T <br />