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a <br /> STATE OF CAUFORMASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM ACOMPLETE THIS FORM FOR EACH FACILITYISITE <br /> PARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED I <br /> ONE REM 2 INTERIM PERMIT O 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> LL 071' L ^' <br /> ADDRESS NEAREST CROSS STREET d.�1 PMCELB(OPfIONAL) <br /> 7 2 <br /> CITU E STATE IP CODE SITE PHONE A WITH AREA CODE <br /> L NAM �` Ca S <br /> TI/ BOX TE f�CORPORATION `t9 INDIVIDUAL PARTNERSHIP LOCAL-AGENCY [71CGUNTY.AGENCY• O STATE-AGENCY' O FEDERALAGENCY' <br /> DISTRICTS' <br /> N owner Of UST Is a public agency,mnplete the following:name of Supervisor of dNlabn,section.m oMice which operates the UST <br /> TYPE OF BUSINESS , 1 GAS STATION 0 2 DISTRIBUTOR � RESERVADION a OF TANKS AT SITE E.P.0. I.D.a(apflo'wl) <br /> Q 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS 1 443 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> �S <br /> NIGHTS: NAME(LAST,FI ST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> LQ <br /> MAILING OR STREET ADDRESS � Vbox bindbaN � INDIVIDUAL 0 LOCAL-AGENCY EDSTATE-AGENCY <br /> 01214/ <br /> CORPORATION O PARTNERSHIP COUNrYAGENCV Q FEDERAL-AGENCY <br /> - CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> Ch =_, SIS - <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> LLD/ <br /> MAILING ORSTREET ADDRES /,w ✓ box bindicaN 'INDIVIDUAL O LOCALAGENCV O STATE-AGENCY <br /> CORPORATION O PARTNERSHIP O COUNTY AGENCY 0 FEDERALAGENCY <br /> CITY NAMESTATE ZIP CODE PHONE a WITH AREA CODE <br /> 7 9 / sv - <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> V(TK) HQ [4g]- 0 D <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ blMbale Q 1 SELF INSURED 2 GUARANTEE 3 INSURMCE O 4 SURETY BOND <br /> f�5 LETTEROFCREDT 6 EXEMPTION ge 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.O I.O Ill. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED S SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY#"7af 7 <br /> m X3-& 11 <br /> LOCATION OE -OPTIONAL CENSUS TRACr,Ti-�TIONAL SUPVISOR-DISTRICTCODE -OPTIONAL 1� -. I / <br /> [ 5, L <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 9-k, <br /> FORM A(393)61 Khl S5 7 <br /> fOR'XA1AA <br /> l <br />