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STATE OF CALIFORNIA ^�eoon e <br /> STATE WATER RESOURCES CONTROL BOARD <br /> Cl UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> e <br /> COMPLETE THIS FORM FOR EACH LRY/SITE <br /> Irp N� <br /> :j <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT <br /> ONE ITEM 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT <br /> ❑ 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACIUTV NAME <br /> NAME OF OPERATOR <br /> ADDRESS <br /> co) /- NEARESTCROS3 STREET PARCEL 0(OPTIONAL) <br /> CITYNAME / 3 �(-J�j n 5`f _ <br /> STATE ZIP CODE SI TE PHONE*WITH AREA CODE <br /> BOX CA otd <br /> TOINO'CATE CORPORATION INDIVIDUAL D pARTNERSHIP 0 LOCAL-AGENCY <br /> 11��aiAA33 DISTRICTS COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> TYPE OF BUSINESS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN MOF TANKS AT SITE E.P.A. I.D. <br /> 3 FARM ❑ 4 PROCESSOR 5 OTHER O RESERVATION (aPl/ma11 <br /> �n <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•oPflonal <br /> [NGEHTNMA <br /> (LAST,FIRSn PHONE*WITH AREA CODE <br /> / DAYS: NAME(LAST,FIRST) <br /> E(LAST,FIRST) !� U - q v� TU <br /> PHONE*WITH AREA CODE NIGHTS: NAME(LA ST.FIR3T) Ell <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> [MA <br /> -/ s CARE OF ADDRESS INFORMATION <br /> GORCC /qq / NDMDUAL� S . 6 ! D LOCAL-AGENCY0 S1ATE-AGENCY <br /> AME / � O CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY D FEDERAL-AGENCY <br /> c.S 7Av L T_ STATE ZIP CODE PHONE M WITH AREA CODE <br /> �-e� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> CARE OF AODRES3 INFORMATION <br /> Su µL C J <br /> MAILING OR STREET ADDRESS ✓ box birdkale <br /> 0 INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> CITY NAME D CORPORATION D PARTNERSHIP D COUNTY-AGENCY 0 STAFEDERAL-AGENCY <br /> TE 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 F4-J-4]- <br /> V. PETROLEUM UST FINANCIA SPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Dox blMkaN 1 SELF-INSURED 0 2 GUARANTEE D 0 INSURANCE D 4 SURETYBOND <br /> D 5 LETrEROFCREDIT D 6 EXEMPTION D 99 OTHER <br /> A. 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.O II. III.❑ <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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY M *67A <br /> LOCATION CODE -OPTKNVAL CENSUS TRACT* -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL �J ✓ <br /> � <br /> a3 J <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 Is 91) <br /> FOR6Si6A.5 O" <br />