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STATE OF CALIFORNIA �,• �'s <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION 3T, <br /> - F R" A i <br /> 0 ,c <br /> COMPLETE THIS FORM FOR EACH F CILITY.'SITE — <br /> MARK ONLY ❑ 1 NEW PERMIT C 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMA So <br /> CNE ITEM 1 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> CBA OR FACILITY NAME NAME OF OPERATOR <br /> � ,� GFov . I�S Irl <br /> ACCRESS NEAREST CROSS STREET PARCEL 9(OPTIONAL) <br /> CITY NA',sE I STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> CA <br /> TO DICOATE CI CORPORATION Q INDIVIDUAL Q PARTNERSHIP (=LOCAL-AGENCY Q COU AGENCY Q ATE•AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS U 1 GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN 0 OF TANKS AT SITE E.P.A. I.O.s(optional) <br /> RESERVATION 3 <br /> C1 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY NTA ERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST)_ PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> 1.(. _ `•. / <br /> NIGHTS: NAME(LASTFIRST) PHONE is WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PWCNF it WITH AREA COOF <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAtdEw , CARE OF ADDRESS INFORMATION <br /> S�/d t& lea (d f felT- <br /> MAiUNG OR STREET ADDRESS ✓ box to indicate <br /> Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP (J COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> 7 O <br /> Ill. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box 0 indicate <br /> Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION QJ PARTNERSHIP Q COUNTY-AGENCY Q 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 44U JZI c 0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box b indicate Q 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> (� 5 LETTER OF CREDIT Qj 6 EXEMPTION Q 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: I.= II.= UL <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY w, <br /> COUNTY# ��„/T JURISDICTION# FACILITY# <br /> LOCATION COD -OPTIONAL (CENSUS TRACT• —TONAL I SUPVISOR-DISTRICT CODE •OPTIONAL <br /> - v' <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) <br /> fCRtXg3A-5 <br />