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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD if <br /> UNDERGROUND SZ11TEGTHIS <br /> TANK PERMIT APPLICATION - FORM A �� ua <br /> . , o <br /> C�ll�on N,� <br /> C FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM O 2 INTERIM PERMIT d AMENDED PERMIT ! TEMPoRARV SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACA N - NAMEOFOPERATOR <br /> 0-e-/ -Z-ra a s D15-t fD Ca / Tl-� <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAU <br /> / f 7C <br /> C� <br /> CITY NAPE -51/pSTATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> TOMMATE O C40RPORATKNI I]INDIVIDUAL 0 PARTNERSHIP Q LOCAL AGENCY L�] COUNTY-AGENCY O STATE-AGENCY L�:j FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 I GAS STATION Q 2 DISTRIBUTOR 0 RESE F INDIAN <br /> N #OF TANKS AT SITE E.P.A. I.D.A(oplinnal/ <br /> O 3 FARM O d PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FM!'n PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> ry wYT Cly. �.s �b9-9Y� — 7y AREA CO <br /> NIGHTS: NAME(LAST.FIRST) PHONE,F VAM AREA CODE NIGHTS: NAME(LAST FIRS)L PHONE I WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> LL a r S <br /> MAILING OR STREE,T ADDRESS ./6n b4MbeN f�INDIVIDUAL EDLOCAL ED <br /> STATE-AGENCY"- <br /> Q 3 V CORPORATION = PARTNERSHIP 0 COUNTYAGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> S <br /> �/ ysz�/ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> L- <br /> MAILING ORSTREET ADDRESS• Wxb Amiome = INDIVIDUAL O LOCAL-AGENCY (]STATE AGENCY <br /> CORPORATION O PARTNERSHIP O COUNTY-AMNCY (] FEDEPAL44ENCY <br /> CITY NAMESTATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD 0 EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - g�3 O G <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECOMPLETED)—IDENTIFYTHEMETHO USED <br /> ✓ box minGkala I SELF-INSURED 0 2 GUARANTEE E::1;,ims10RANcE O I SURETY BOND <br /> D 5 LETTER OF CREDIT 6 EXEMPTION Ekofag 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 chec <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= it. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLCANTS NAME(PRINTED A SIGNATURE) APPLICANTSTITLE DATE MONTHIDAVIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# coc-re 9 <br /> 7- <br /> LOCATION CODE -OPT NAL !CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OP7/ONAL <br /> n a 3ep ISas— Lia X93 <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(12911FILE THIS FdRM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIO <br /> FOR00?tA-Pe <br />