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EB��e B <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD n ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> C�l,�Oe N,N <br /> COMPLETETHIS FORM FO!!ACH F CILrrYtSITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ ir PERMANENTLY CLO SEE - <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE C�.Y/ <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME V '_LL <br /> NAME OF OPERATOR <br /> �rC�t F. <br /> ADDRESS���y� C4� r` NEAREST CROSS STREET PARCEL#(OPTNNLIL) <br /> CITY NAM 11.- STATE ZIP CODE SITE PHONE+i WITH AREA CODE <br /> 4 \.rCDCA 5336 o4 SS-y//y <br /> ✓ BOX <br /> TO INDICATE L--3CORPORATION L-1INDIVIDUAL0 PARTNERSHIP I�LOCAL-AGENCY <br /> OCAL- G NCY E COUNTRAGENCY TATE-AGENCY l� FEDERALAGENCY <br /> DISTRITYPE OF BUSINESS T GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(apfhnal) <br /> flESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE&WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME11tt CARE OF ADDRESS INFORMATION / <br /> C1fC`G O SMZT� <br /> MAILING OR STREET ADDRESS ✓ WXIPNXI AI9 I= INDIVIDUAL D LOCAL AGENCY D STATE AGENCY <br /> O160* 5 Zp 0 CORPORATION Q PARTNERSHIP E�]COUNTY AGENCY O FEDERAL-AGENCY <br /> CITY NAME.n STATEZIP CODE P NE# ITH AREA CODE <br /> Q1�c�n�X r S07 L OZ 7kel <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bmbindmM INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> 0 CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#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 - 0 0 3 2 (o D <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓bm bMute = I SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETYBOND <br /> 0 5 LETEROFCREDT =6 EXEMPTION = 99 OTHER <br /> Vl. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is chedm <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ II. 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 8 SIGNATUREI APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# CIREt— lb <br /> -1-71 [2- 131115 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL � SUPVISOR-DISTRICT CODE -OPDONAL <br /> J <br /> J v 'L fo <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SIT NFORMATION ONLY. <br /> FORM A(12-9u FILE THIS FORM WITH THF-LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIO <br /> ` — FORW33A R6 <br /> Y <br />