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PeyouRc;s c <br /> * STATE OF CALIFORNIA P• °? <br /> 9 <br /> STATE WATER RESOURCES CONTROL BOARD W , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A d <br /> •C�(IFp1t N� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F__] 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA FACIL eNA j ( L)F NAMEOFOP ITOR <br /> Ra <br /> C <br /> ADD SS 94 <br /> V�nS NEA E'TCPPCSSTREEyC� PARCEL#(OPTIONAL) <br /> CITY E, IF STATE ((��VVZI CODEtt��� SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓ BOX CORPORATION [] INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> TO INDICATE DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR = <br /> ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESE RVAT ION <br /> 3 FARM 4 PROCESSOR& <br /> 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DA NAM AST, T) P E WIT A C E D NAVE(LAST,FIRS <br /> PHONE#WITH AREA('0nF <br /> NIGHTS: NAME(LAST,FIRST) I PHONE#WITA AREA CODE HTS: NAME(LAST,FIRST) <br /> PHONE#WITH A EA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAM , - CA OF AWRESS INF M ION <br /> aC C Gt <br /> MAILING OR STREET RESS ✓box to indicate 0 INDIVIDUAL OCAL-AGENCY STATE-AGENCY <br /> aCl171 lA �-��J CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NA E STj1,Ir ZIP CQD 'S3^ PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM F OW ^ �el CARE ADDRESS I FORMATION <br /> a(I LC <br /> r o *Z <br /> MAILING OR STREET ADDR SS ✓ box to indicate DIVIDUAL OLOCAL-AGENCY STATE-AGENCY <br /> f 2 �V�n�Q INCORPORATION = PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY E h STA ZIP 3162 PHONE#WITH AA C�OQE C' <br /> e's <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. .rlti)• (xJ <br /> TY(TK) HQ 4 4 -161 1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> = 5 LETTER OF CREDIT 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: I.= II.= III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME�ED 8 SIGNATUR APP CANTS TITLE DATE MONTH/DAY/YEAR <br /> sh UmLOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> mFT77 I RI�15q <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OP NAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> C 3. 9 <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) 4.T6 FOR0033A-5 <br /> �r ,A <br />