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R <br /> STATE OF CALIFORNIA ."~ ®w`•° s <br /> STATE WATER RESOURCES CONTROL BOARD 3 mom, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT F7 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> oolsii:. 4 v��-• <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> Z p. t s r - JU <br /> STATE— <br /> CITY NAME ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA t <br /> TO INDICATEORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION , 2 DISTRIBUTOR ® ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I,D.#(optiatal) <br /> RESERVATION <br /> Q 3 FARM 77 4 PROCESSOR EE1115, <br /> 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 /> L %k <br /> NIGHTS: NAME(LAST,FIRS PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 4� ,. <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> N.!W CARE OF ADDRESS INFORMATION <br /> l ` Wt L <br /> MAILING OR STR ET ADDRESS ✓ box No indices INDIVIDUALLOCAL-AGENCY <br /> Q Q STATE-AGENCY <br /> V. It Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE I ZIP CODE PHONE#WITH AREA CODE <br /> 6.A 3., 1/2 0 CA CIS I • <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> r— <br /> MAILING OR STREET AO RESS ✓ box ID indicate ® INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> ORPORAnON Q PARTNERSHIP ® COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODES PHONE#WITH AREA CODE <br /> G <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ T 47 -I 1 I� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box q indkate ® t SELF-INSURED ®2 GUARANTEE 0 3 INSURANCE Q 4 SURETY BOND <br /> ®5 LETTER OF CREDIT Q 6 EXEMPTION Q 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. II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> PLANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> s0 ^— <br /> LOCAL AGENCY USE 0 <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 />