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�so�a es <br /> STATE OF CALIFORNIA 46 �ev Jz <br /> P oa <br /> P <br /> w 9 <br /> STATE WATER RESOURCES CONTROL BOARD w , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A o0 <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLYNew PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSEO''. <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME V NAME OF OPERATOR <br /> 6 Olt] <br /> ADD�ES�05 % N REST CROSSSTRE T PARCEL#(OPTIONAL) <br /> ���L//,,((//�� , <br /> CITY NAME STAT ZIP CODE SITE PHONE#WITH AREA CODE <br /> y� CA <br /> ✓ BOX <br /> TO INDICATE 0 CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN I#OF TANK AT SITE I E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR = 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 /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA Conp <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindicate INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 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 F4-F4]-10 JZ JqTT-S F47 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE CO LETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 0 1 SELF-INSURED EV2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> E:71 5 LETTER OF CREDIT = 6 EXEMPTION O 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: L E:1 II.0 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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> Cif,'Vl2 z9 �yJy��/ <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> dl 23 . 1 2 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- F ,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(5-91) FOR0033A•5 <br /> i4�r j// <br />