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N__/ " e <br /> STATE OF CALIFORNIA <br /> s <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> �•(�.Oe M.e <br /> � CO LETS THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY El 1 NEW PERMIT RENEWAL PERMIT 5 CHANGE OF INFORMATION [:] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM u 2 INTERIM PERMIT 4 AMENDED PERMIT 0 S TEMPORARY SITE CLOSURE DZ <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA F ILTYNAME // � NAME <br /> R <br /> / <br /> NEARESTCRSTREET <br /> T PARCEL#(OPfgNAL)/ w. Vh <br /> CITSTATE <br /> ZIPD� SITE PHONE#WITH AREA CODE <br /> CA <br /> TO INDICATE [_1 CORPORATION I]INDIVIDUAL PARTNERSHIP I]LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY I] FEOERALAGENCY \ <br /> DISTRICTS <br /> TYPE OF BUSINESSO 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN DFTANK AT SITE E.P.A. -1:0:1f(Op#pl2n <br /> '—' RES€RVION 5 <br /> 3 FARM O 4 PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA MOP <br /> NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) WITH AREA COOF <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NA CARE OF ADDRESS INFORMATION <br /> AO <br /> MA O TREET DRESS '� ✓boa b III 0 INDIVIDUAL I� LOCALAGENCY STATEAGENCY <br /> �- 6038 O CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY ] FEDERAL#GENCY <br /> CI 1�N E .� Si ZI D PHONE x WITH AREA DE <br /> A. 4 Z- 3/b-�p <br /> III. TANK OWNER INFORMATION-(MUST 9 COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MA IREEM ESS• O^ ✓ bua bintlicme INDIVIDUAL E-1LOCAL-AGENCYI] STATE AGENCY <br /> z s (]CORPORATION PARTNERSHIP 0 COUNTYAGENCY 0 FEDERAL-AGENCY <br /> TY N - S PHONE x WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION LIST STORAGE <br /> STFEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> 7-VTY(TK) HO F4774 - <br /> V. <br /> . PETROLEUM UST FINANCIA ESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bm bintlicaleEv SEUNNSURED I]2 GUARANTEE [1] 3 INSURANCE SUREIV POND <br /> 5 LETTER OF CREDIT I]6 EXEMPTION C] 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II' ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.D IL I�. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AN F O RRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANYSTITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It FA�Cl/LITI/Y/# <br /> I F1 <br /> 71 <br /> _()CATION CODE - pIONAL CENSUSTRACTO�OPj CWAi6O T <br /> SUPVI ICT CODE -OPTIONAL <br /> THIS FORM Mt Iqt BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION� FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0033A RE <br /> V V <br />