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�eoun es <br /> STATE OF CALIFORNIA hee cOr <br /> STATE WATER RESOURCES CONTROL BOARD a �, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a �a <br /> •C-[-pn N`• <br /> COMPLETE THIS FORM FOR EA4H FACILITY/SITE <br /> MARK ONLY D 1 NEW PERMIT 3 RENEWAL PERMIT HANGE OF INFORMATION a PERMANENTLY CLOSED SITE <br /> ONE ITEM JI 2 INTERIM PERMIT 0 4 AMENDED PERMIT 4r6 TEMPORARY SITE CLOSUreo,.t) <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> g <br /> ADDRESS J NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA Lu <br /> TO INDICATE C71ATION (] INDIVIDUAL (] PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY (] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR / IF INDIAN IS OF TANKS AT SITE E.P.A. I.D-9(optional) <br /> RESERVATION <br /> 0 3 FARM 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 /> E � 19 4 PHONE a WITH AREA rnnP <br /> NIGHTS: NAME(LAST,FI ST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 5 (� -k� PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 6( `u rn w> k c <br /> MAILING OR STREET ADDRESS r ✓ box b indicate 0 INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> f rj s` �� 3, d• CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME ( <br /> STATE ZIP CO3 3.6 P�NE#WITH AREAsCODE <br /> � G <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> _ 5 & s-� u S <br /> MAILING OR STREET ADDRESS• ✓ box bindicate Q INDIVIDUAL Q LOCAL-AGENCY (] STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME' STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATIONi UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 14 14]-[(3-1 ZI2—" <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate .] 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> LJ 5 LETTEROFCREDIT 0 6 EXEMPTION Q 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.O IL 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&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# / Q 19FJyCC Z/ <br /> !3I7 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL I SUPVISOR-DISTRICT CODE -OPTIONAL <br /> z 3 AT o 3Z-2, Co <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(12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR00'5A R6 <br />