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'�gO�A f <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w�� �e <br /> o. <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION V7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE So <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME cc yy NAMEOFOPERATOR <br /> - / <br /> _/CkIN.l�tY H(.GSfT_ ffA <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTPJNAU <br /> 4 3S- a S <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> S*C CA <br /> I/ Box <br /> TOINDICATE D CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP [71 LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ -/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optla W) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRS PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> N 2ZPHONE 9 WITH AREA rOOF <br /> NIGHTS: NAM LAST,FIRST) PHONE <br /> 'WI WITH AREA CODE NIGHTS: NAME(LAST,FIRST) Coup <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> ry CARE OF ADDRESS INFORMATION <br /> C <br /> MAI GOR STREET ADDRESS /�) ✓box bindiwte OINDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> O � 2D, 6 - / 0 CORPORATION 0 PARTNERSHIP COUMYAGENCY E--I FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> QY o 12091-?V2-"2z- <br /> Ill. <br /> - 2a9- y2-"2ZIII. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxbindbaW 0INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION = PARTNERSHIP Q COUNTY-AGENCY (] 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 44 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bbbkab 0 1 SELF-INSURED =2 GUARANTEE i= 3 INSURANCE 0 4 SUREIY BONG <br /> D 5 LETTER OF CREDIT 0 6 EXEMPTION E71 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II IVIII.❑ <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 MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ® © _-0fcK163 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 23• $D v-3 S <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) ✓ / FORD033A5 <br />