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rN <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3 '; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY EW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT 0 d AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 1 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> SL-L C r <br /> ADDRESS NEAREST CROSS STREET PARCELa(OPTIONAL) <br /> y/ f, Ckaw�u Q9 <br /> CITY NAME STATEZIP CODE SITE PHONE a WITH AREA CODE <br /> CA YS.)4(. <br /> BOX <br /> TO INDICATE CORPO ION INDIVIDUAL =1 PARTNERSHIP 0 LOCAL-AGENCY Q COUNTY AGENCY 0 STATE-AGENCY Q FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESSI GAS STATION 2 DISTRIBUTOR 0 ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.s(cWknal) <br /> RESERVATION <br /> O 3 FARM O A PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME <br /> ��(LAST.FIRST) ll PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> _a 2HONE a WITH AREA CODE_ <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME A t A.cl CARE OF ADDRESS INFORMATION <br /> 5c, c(a� <br /> MAILING OR STREET ADDRESST ✓ bDt bk&a Q INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> 9 i X Ldei //A . 0 CORPORATION 0 PARTNERSHIP Q COUKrY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> WeS Sa c �G n r.�lv CA (o l <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 54 a,,'e <br /> MAILING OR STREET ADDRESS ✓ box k,fokm E-1 INDIVIDUAL 0 LOCAL-AGENCY STATE AGENCY <br /> =CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERALAGENCY <br /> CIN NAME STATE ZIP CODE PHONE i WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 p a i( 8 <br /> V. PETROLEUM UST FINANCI ESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHODS) USED <br /> ✓ bot binOkale 1 SELFINSURED 0 2 GUARANTEE 0 3 INSURANCE d SURETY BOND <br /> O 5 LETTEROFCREDIT E-16 EXEMPTION 59 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.O III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED A SIGNATURE) APPLICANTSTITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION IT FACILITY# TO"Xi AA0 <br /> 3'5 TE FFU3 <br /> LOCATION CODE -OPTIONAL ICENSUSTRACT iI -OPTIONAL SUPVISOOR-DISTRICT COD TIONAL ��� <br /> b d!; 37-3 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY. <br /> 01410 All 2-Btl FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS / FOR0033A R6 <br />