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I <br /> m cgoua e <br /> I STATE OF CALIFORNIA <br /> w STATE WATER RESOURCES CONTROL BOARD W <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> •c41Pp RN� <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> i <br /> I MARK ONLY F-11 NEW PERMIT f73 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM a P <br /> I. F ITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA FACILITY NAME NAME OF OPERATOR <br /> DRESS NEAREST ROSS STREET PARCEL#(OPTIONAL) <br /> I v <br /> �ITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> I/ BOX <br /> TO INDICATE Q CORPORATION Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY AGE STATE-AGENCY Q FEDERAL AGENCY <br /> DISTRICTS <br />`.,. <br /> t COFESS I GAS STATION ❑ 2 DISTRIBUTOR ✓ IF IN #OF TANKS AT SITE I E. .A. I.D.#(optional) <br /> RESERV ION <br /> I 0 3 FARM Q 4 PROCESSOR ❑ 5 OTHER _, OR TRUST DS <br /> fEMERGENCY CONTACT PERSON (PRIMARY) EMERGE (SECONDARY)-optional�J <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS:NAME(LAST,FIRST) <br /> -cA/-?t-1Al PHON 11= <br /> s'rvc�t7a2 > rvt t �N <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 1-7 o a4-7 <br /> f <br /> i II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILINGORSTREET ADDRESS �" ✓ box toindicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> 3(� 3 e Gt 6�(/ /U V Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> I CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> i <br /> II. TANK OWNER INFORMATION (MUST BE COMPLETED) <br /> NAME OFOWNER // CARE OF ADDRESS INFORMATION <br /> I MAILING OR STREET ADDRESS ✓ box b indicate <br /> L Q INDIVIDUAL QLOCAL-AGENCY QSTATE-AGENCY <br /> I CIN NAME STATE <br /> P�Q PARTNERSHIP Q PHOCOUNE#WITCH AREA OEERAL-AGENCY <br /> ��� -9555 if questions arise. <br /> TY(TK) HQ F4-T74 - q O� <br /> i V. PETROLEUM UST FINANCIA ESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate t SELF-INURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> i Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank ownerless box I or II is c ed. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: _?.�� I. IL III.❑ <br /> fTHIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# tN A 7 EA 36 <br /> 3q 23. 175 ' <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR•DISTRICT CODE •OPTIONAL <br /> I <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANCE QUITE INFORMATION ONLY. <br /> i <br /> FORM A(5.91) VL �(/`, �A/.-�5 <br /> E <br />