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STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />C✓ COMPLETE THIS FORM FOR Ea2H FACILITY/SITE <br />MARK ONLY 0 1 NEW PERMIT F__] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION D 7 PERMANENTLY CLOSED SITE <br />ONE ITEM E::] 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE rF <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA Q,�i FACILITY NAM ��0Z <br />G�i/'`����G <br />NAME OF OPERATOR <br />ADDRESS <br />0_2CITY <br />NEAREST ROS,SSTREET <br />PARCEL #(OPfIONAI) <br />NAME <br />STATE <br />ZIP CODTE <br />ofd Zf�� <br />PH NE # WITH AREA COD <br />rSZ' 02 <br />CITY NA <br />9`� <br />CA <br />ZIP CODE <br />e,7323 <br />HONE WITH AREA CODE <br />5S-2- -6Z41 <br />✓ BOX <br />TO INDICATE CORPORATION INDIVIDUAL 0 PARTNERSHIP 0 LOCAL -AGENCY (] COUNTY -AGENCY (] STATE -AGENCY (] FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR <br />0 ,/IF INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />3 FARM 4 PROCESSOR = 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST FIRST) P ONE # WITH AREA CODE <br />4_-1AM avi) 3m-1;5_6 <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHT/S: ,NAAjM•E (LAS- FIRST) PH NE # WITH AREA C09� <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA COOP <br />II_ PROPFRTY OWNFR INFORMATION - (MUST BE COMPLETED) <br />NAME � <br />�z /' C iiyJ, " <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS^ <br />✓ box toindicate INDIVIDUAL <br />(� LOCAL -AGENCY Q STATE -AGENCY <br />!O ����Y <br />CORPORATION 0 PARTNERSHIP <br />0 COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NA <br />9`� <br />STATE <br />�4' <br />ZIP CODE <br />e,7323 <br />HONE WITH AREA CODE <br />5S-2- -6Z41 <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />d c/ d?"� Lo . <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS -� <br />", <br />^��� <br />✓ box to Indicate INDIVIDUAL <br />LOCAL -AGENCY <br />0 STATE -AGENCY <br />(�i! It/! <br />` <br />CORPORATION PARTNERSHIP <br />COUNTY -AGENCY <br />0 FEDERAL -AGENCY <br />CAE E <br />/Xirv�l� <br />STATE <br />IeA- <br />ZIP CODE <br />q 3Z3 0 <br />HONE # WITH AREA CODE <br />to"Oet) *z - 6;'z -41j 1 <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />TY (TK) HQ4 4- o I 0 I o I v <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 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. ❑ IL ❑ 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 />101011 <br />LOCATION CODE -OPTIONAL CENSUS TRACT # -OPTIONAL SUPVIS R - DISTRICT CODE - OPTIONAL n d q <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ON <br />FORM A(5-91) FORO 3A. <br />1p 0 t&l <br />