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e,oURCes <br /> STATI:OFCALIFORNIA r. . cU <br /> STATE WATER RESOURCES CONTROL BOARD 3 o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION f0 M'A g,�y <br /> C�(IFON N,♦ <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> ��".�r i <br /> (MARK ONLY � 1 NEW PERMIT F—] 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATIDNe LI 7 PtR AMEN <br /> ONE ITELA 2 INTERIM PERMIT a 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMES�fNAME OF OPERATOR 4r Ir <br /> ADDRESS 2--705- Cru v? NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> f� �� <br /> CITY NAME P,(r <br /> `�v STATE ZIOD SITE PHONE#WITH AREA CODE <br /> N CA 5-E �—'— <br /> ✓ BOX CORPORATION INDIVIDUAL =PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY E::] STATE-AGENCY FEDERAL-AGENCY <br /> TO INDICATE r _ DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN I#OF TANKF AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> O 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: ME(LPST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> vr, l 0'd /5-673-V6 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> ,PHONEPHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> C , <br /> MAILING,gR STREET ADDRESS ✓ box io indicate INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> ;SORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY N - I STATE ZIP CODE PHO E#WITH AREA CODE <br /> - 70f 2--- - a <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWVFITLn /L CARE OF ADDRESS INFORMATION <br /> MAILING,PR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> 75-6-() Gt �ORPORATION = PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHO E#WITH AREA CODE <br /> �' '7 0 G�- 2-- <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - d 10 C� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USE7 <br /> ✓ box b indicate )S;I-j SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> =5 LETTER OF CREDIT 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.0 II.0 III.O <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) AP LICANTS TITLE DATE ONTH/DAV AR <br /> KE 9A 1, , ,� 5 Z 9 v I <br /> LOCAL AGENCY USE ONL -�� <br /> COUNTY# JURISDICTION# FACILITY# <br /> JTZ`, <br /> LOCATION CODE - TIONAL CENSUS TRACT is gTIONAL SUPVISOR-D T ICTCOD - TIONAL <br /> z7_ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATIO ONLY. <br /> FORM A(5-91) < FOR0033A-5 <br />