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STATE OFCAUFORNIA t e. ��"i, <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� <br /> COMPLETE THIS FORM FOR EACH FACILrTYISITE <br /> MARK ONLY ❑ I NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION le7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT O A AMENDED PERMIT S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACIUtyNjRU NAME OF OPERATOR <br /> ADDRESS NEAREST CROSSSTRE PARCEL#(OPTN)N,Ly <br /> i.7YY s. %o.,o <br /> CITY NAME STATE ZIP CODE SITE PHONE s WITH AREA CODE <br /> CA s zoi <br /> ✓sox <br /> TO INDICATE O CORfdvorm O INDIVIDUAL I1 PARTNERSHIP Q LOCAL-AGENCY O COUNTYAMNCY O STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Q t OAS STATION Q 2DISTRIBUTOR O ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. L D.#rgW.1) <br /> - 5 OTHER OR RESERVATION / <br /> Q 3 FARM O 4 PROCESSOR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(UST.//FNilp PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(WT.FIRST) E a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME //// / CARE OF ADDRESS INFORMATION <br /> /141/ry Stix <br /> MAILING OR STREET ADDRESS ✓ OarblMk INDIVIDUAL Q LOCAL-AGENCY O STATE-AGENCY <br /> /-",(,, 3v�c �l6G L/ Q CORPORATION O PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME fC STATE ZIPb PHONE t WITH AREA CODE <br /> ,SAV <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> G ye 4S <br /> MAILING OR STREET ADDRESS- twr bMkkale INDIVIDUAL 0 LOCAL-AGENCY L,i STATE AGENCY <br /> CORPORATION D PARTNERSHIP COUNTYAGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD 0 ECIUALRATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 1 F413 Z MI(o <br /> V. PETROLEUM UST FINANCIAL RE$PONSIBILITY-(MUSTBECOMPLETED)—IDENTIFY THE METHO USED <br /> ✓ Wx bmcale = 1 SELF INSURED L�j 2 GUARANTEE URANCE =1 d SURETY BOND <br /> =5 LETTER OF COEDIT = 6 EXEMPTION Elf 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 is ch ed. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L O 11. TIL n <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 3 9 i L= I� � <br /> LOCATION CODETIONAL I CENSUS TRACT OPRONAL SUPVISOR;ISTRICT CODE -OPTIONAL V/?- 7 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE I FORMATION ONLY. <br /> FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> - FOR00T3AP1 <br />