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• �Peb'OU <br /> STATE OF CALIFORNIA <br /> 9 <br /> STATE WATER RESOURCES CONTROL BOARD w , <br /> iNIDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ; <br /> •C�[If OP N.� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT F__] 3 RENEWAL PERMIT F—] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 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 /> tom, 0' I <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> 1102 r 1 <br /> CITY NAME STATE ZIP CODE SITE PH NE#WITH AREA CODE <br /> CA 20 q - <br /> ✓ BOX <br /> TO INDICATE O CORPORATION (] INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR / IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> LA <br /> h e en e Q 3 -Zoe 15a n i <br /> PHONE#WITH AREA COOF <br /> NIGHTS: NAME(LAST,FI ST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST, IRST) IS--f_5357 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bo Indicate INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> Gfpi�c-r 3(0a LCORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CI AME STATE ZIP CODE eHONWITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NA CARE OF ADDRESS INFORMATION <br /> a _ <br /> MAILING OR STREET ADDRESS ,=' sV ✓box Indicate INDIVIDUAL © LOCAL-AGENCY STATE-AGENCY <br /> 1'__ C/ORPORATION ©PARTNERSHIP [`COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME $TATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOA QUALIZATION UST STORAGE FEE ACCOUNT NUMBER all(916)323-9555 if questions arise. <br /> TY(TK) HQ4 4 - p Z 4 q �$ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE THOD(S) USED <br /> ✓ box IDindicate O 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> D 5 LETTER OF CREDIT Q 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: 1.[:1 II.E] 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(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ® MUB IL 03 1 11 ici 19 L5T gzlaz <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL I J <br /> 23, 321 T <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) FOR0033A-5 <br />