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STATE OF CALIFORNIA ^revue a c� <br /> STATE WATER RESOURCES CONTROL BOARD ;� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A `� m <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE "�•^,. <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 2T CHANGE OF INFORMATION ❑ 7 PERMANENTLY <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> S ' I ,,#„ <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTKRUq <br /> 30 GaC7l4 <br /> CITY NAME STATE 21P CODE SITE PHONE#WITH AREA CODE <br /> 8'I CA <br /> TOINUC TE O CORPORATION Q INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY 2ff—COUNTY-AGENCY STATE-AGENCY FEDERAUAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION 0 2 DISTRIBUTOR I ❑ ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(opti ml) <br /> RESERVATION <br /> O 3 FARM O 4 PROCESSOR 0 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 /> ec- A oc 205.5 - 7-1 3 Swe4c <br /> NIGHTS: NAM (LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA GO <br /> StMC <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING CA STREET ADDRESS II ✓ box bindicMe [—I INDIVIDUAL Q LOCAL-AGENCY O STATE-AGENCY <br /> 30` Lq L/ =CORPORATION Q PARTNERSHIP COUNTY.AGENCY FEDERAL#GENCY <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 ✓ box b Wmw INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> O CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 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 F41 4 - 4 L <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓bobIlxllcaN (] 1 SELF-INSURED 0 2 GUARANTEE INSURANCE 4 SURETY BDND <br /> 5 LETTEROFCREOIT I�6 EXEMPTION O 99 OTHER <br /> 771 <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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L[fl'— 11.❑ 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 6 SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# ^ 'cD <br /> 35 F-Ss I I 1 -� <br /> LOCATION CODE -OP TONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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(5-91) FOR0033A 5 <br />