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`601R C <br /> STATE OF CAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W mfr ,Ip <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C4IFURH' <br /> MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE U� <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS ` - } NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 1 1 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> -v CA Z09 833- / <br /> TO TE CORPORATION �INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' (]STATE-AGENCY FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 0 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) n PHONE#WITH AREA CODE <br /> < ( 7z7-7 c�L 707-751s=,61,9 <br /> NIGMME(LAST.FIRST) PHONE#WITH AREA CODE NIGH AME <br /> (LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> ANAME CARE OF ADDRESS ORMATION <br /> TREE DRESS ✓ boxbindicate 0INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATIONPARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OFcWNEa CARE OF ADDRESS 1 ORMATION <br /> .7Y18? r t/,Gly / es Q -7 <br /> MAILINGfOR <br /> �S'}TREET A15DRESS ✓box to indicate 0 INDIVIDUAL LOCAL-AGENCY (]STATE-AGENCY <br /> CO ORPORATION = PARTNERSHIP COUNTY-AGENCY E::] FEDERAL-AGENCY <br /> CITY NAM S TE ZIP CODE PHONE AREA CODE <br /> �D 7 <br /> 7VS- 6(/o <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916))332222-9669 if questions arise. <br /> TY(TK) HQ 4 4-1-loll jej5jc?ji <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box lo Indicate 1 SELF-INSURED 0 2 GUARANTEE INSURANCE 4 SURETY BOND <br /> O 5 LETrER OF CREDIT Q 6 EXEMPTION 0 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: 1.0 11.X III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED 6 SIGNED) OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> JDJ�r- 62 /2-y-9� } <br /> LOCAL AGENCY USE ONLY f <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 9UPVISOR-DISTRICT CODE -OPITONAL <br /> l z if ?6 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF INFO MAT ON ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUNDSIORAGE TANK REGULATIONS <br /> �) FOROOMM-W <br />