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r <br />3 <br />STATE OF CALIFORNIA A: P <br />STATE WATER RESOURCES CONTROL BOARD s <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />MARK ONLY F- � E:]NEW PERMIT � 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION n 7 PERMANEN OS'a L/ I <br />ONE ITEM Lj�/� 2, <br />INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) / <br />DBA OR FACILITY NAME <br />Z <br />NAME OF OPERATOR <br />7 <br />CORPORATION PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY <br />ADDRESS <br />_ 30/ a / / A- <br />L,.� <br />NEAREST CROSS STREET <br />PARCEL # (OPTIONAL) <br />CITY NAME <br />STATE <br />ZIP/ E / <br />Lv_ <br />SITE PHONE # WITH AREA CODE <br />CA <br />J <br />✓ BOX PORATION INDIVIDU I� PARTNERSHIP (] LOCAL -AGENCY COUNTY -AGENCY <br />TO INDICATE OR0STATE-AGENCY FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR0 <br />INDIAN <br /># OF TANKS AT SITE <br />E. P. A. D. # (optional) <br />R SEIF <br />RVATION <br />3 FARM 0 4 PROCESSOR <br />5 OTHER <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME t _ _ � � � �►/ <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to indicate 0 INDIVIDUAL LOCAL -AGENCY 0 STATE -AGENCY <br />CORPORATION PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER_ ,� CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESSS / SAA <br />fI/�, CT ✓ box ID indicate 0 INDIVIDUAL LOCAL -AGENCY (� STATE -AGENCY <br />t7191- 1,V,11V /A CORPORATION 0 PARTNERSHIP 0 COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NA STATE ZIP CODE PHONE I WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE AICCOUNT NUMBER - Call (916) 323-9555 if questions�r4e. <br />TY (TK) HQ L�4�- <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to indicate L_:j 1 SELF-INSURED 2 GUARANTEE [_1 3 INSURANCE 4 SURETY BOND <br />L_; 5 LETTER OF CREDIT 6 EXEMPTION CJ 99 OTHER <br />VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless bo or II is checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. C] III. E <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) <br />APPLICANTS TITLE <br />DATE MONTH/DAY/YEAR <br />/;;-- Iy <br />LOCAL AGENCY USE ONLY !.✓l'rJ <br />COUNTY # JURISDICTION # FACILITY # <br />LOCATI CODE OPTIONAL i CENSUS TRACT # -OPTIONALSUPVISO ICT E_ -1)0"L <br />Z�Gv .j <br />TWIQ F(1AM AAI ICT AG Af`rn"oAMIGII RV AT I FACT 111 OP tuV1AI- DF:PMIT ADDI ICATInN - POPRA R 1I0 CCQ TNIQ IC A (`41AIJCC !1C CITC IAIC/1DRMATII1N MNL <br />FORM A (12.91) FILE THIS FORM WITH THE LOCAL LGENCY MPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />