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~ • STATEOFCAUFORNIA <br /> r STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EA99 FACILITYISITE <br /> MARK ONLY I_l I NEW PERMIT ] RENEWAL PERMIT 5 CHANGE OF INFORMATION C] 7 PERMANENTLY CLOS SITE <br /> ONE ITEM Cj 2 INTERIM PERMIT A AMENDED PERMIT 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 9 <br /> ,08A OR FACILITY NAME C /L NAME OF OPERATOR <br /> -- <br /> ADDRESS NEAREST CROSS STREET PARCEL t(OPTIONAL) <br /> CITY NAME STATE DP CODE SITE PHONE s WITH AREA CODE <br /> Vl � c CA I 5 3 36 ' <br /> To INDICATE CORPORATION p INDIVIDUAL p PARTNERSHIP p LOCAL-AGENCY p COUNTY•AGENCY p STATE AGENCY p FMERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS I GAS STATION p 2 DISTRIBUTORp ✓ IF INOIAN s OF TANKS AT SITE E.P.A. L 0.a(goaonat) <br /> RESERVATION <br /> I� 1 FARM p 4 PROCESSOR p 5 OTHER <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE t WITH AREA CODE DAYS:NAME(LAST.FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA CODE NIGHTS:NAME(LAST.FIRST) <br /> au NG: C <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> ?111 <br /> . I CARE OF ADDRESS INFORMATION <br /> MAI ING OR STREET ADDRESS ✓ b nm— INDIVIDUAL p LOCAL-AGENCY L_ STATE-AGENCY <br /> Z` IT I �f/✓ t' I p CORPORATION p PARTNERSHIP COUNTY•AGENCY p -memAGENCY <br /> i CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> �.. 1 ?5 7�6 I -2 O l/ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER 7WOF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ o"1)wxwm Q INDIVIDUAL LOCAL-AGENCY C STATE-AGENCY <br /> f j CORPORATION (_1 PARTNERSNIP p COUNIY•AGENCY p FEDERAL-AGENCY <br /> CITY NAME I STATE I ZIP CODE I PHONE t WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4747,-!Q 12-1 L-I �J <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bw O aficaft u I SELF•INSURED 2 GUARANTEE 1_ 3 INSURANCE +SURETY 80N0 <br /> Q 5 LETTEROFCREorr p 5 ECEWMON 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or If is checked. <br /> CHECK ONE 80X INDICATING WHICH A80VE AOORESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND aILLING: L IL= 114 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPUCANTS NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE DATE MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JURISDICTION x L"IA61TY < y� (�K 1 d <br /> Q <br /> LOCATION CODE -OPTIONAL i CENSUS TRACT t •OPTIONAL i SUPVISOR-OISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS <br /> /JIS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(5.91)� � /� t � � fOR0073M5 — <br /> C <br />