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4 [ <br /> STATE OF CALIFORNIA �i <br /> STATE WATER RESOURCES CONTROL BOARD i� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W�� v; <br /> (11_1� COMPLETE THIS FORM FOR EAC#fACILrrYtSrTE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION L� 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5 3 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR CILITYNAME �� NAME OF OPERATOR <br /> Q-hc) <br /> ADDRE � NEAR TCROSS STREET /JA PARCEL 0(OPTIONAL) <br /> E c� 1 P/V CLri L <br /> CITY N STATE ZIP CODEE S PHONE#WITH AREA CO C� <br /> Box CA J <br /> TOINp TE O CORPORATION INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY Q STATE-AGENCY O FEDERAL#GENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O ( GAS STATION ❑ 2 DISTRIBUTOR */ IF INDIAN #OF BRE E.P.A. I.D.#rapdong <br /> RESERVATION <br /> Q 3 FARM O # PROCESSOR ❑ 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) <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> U. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ am bkdk ED INDIVIDUAL LOCAL.AGENCY O STATE-AGENCY <br /> 0 CORPORATION = PARTNERSHIP COUNTYAGENCY ED FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS _-- ✓ OWbWkw INDIVIDUAL LOCAL AGENCY STATE AGENCY <br /> CORPORATION D PARTNERSHIP []COUNTYAGENCY 0 FEDERALABEWY <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- 31921-Z1621 <br /> 2 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COM LETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ lba oiMKate O t SELF-INSURED [� GUARANTEE [:13 INSURANCE O a SURETY BOND <br /> 5 LETTEROFCREDT 6 EXEMPTION = Is 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: L❑ II.❑ 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(PR INTED&S IGNATU RE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> W v o �) 13 <br /> LOCATION Ca 705PPONAL CENSUS TRACT:OPTIOON Z <br /> SUPVISOR-DISTRICT CODE -OPTIONAL <br /> Z B <br /> THIS FORM MUST BE ACCOMPANIED BY AT LE (1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A("1) FOROMM-5 <br />