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STATE OF=FORMA <br /> STATE WATER RESOURCES CONTROL BOARD c o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "� <br /> . , o <br /> -� COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY I NEW PERMIT n 3 RENEWAL PERMIT Or� 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT � u <br /> 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I <br /> I. FACILITY/SITE INFORMATION IS ADDRESS-(MUST BE COMPLETED) <br /> DEA OR FACILITY NAME I � NAMEQFQPERATOR <br /> 1!YLi/9� e F o/ROSS..r <br /> ADDRESS <br /> NEAREST TREE q PARCEIN(OPTgNA4 <br /> CIN AME s Qr <br /> STATE ZIP DOJ. ITE PHONE a WITH AREA CODE <br /> CA <br /> ✓ RDx ,�--,,// <br /> TO INDICATE O CORPORATION [] INDIVIDUAL IA�rARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY O STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ];oj�GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN x OF TANKS AT SITE E.P.A. L D.a(opimap <br /> 3 FARM d PROCESSOR O RESERVATION <br /> 0 � 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonal <br /> DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST FIRS <br /> Gi sera <br /> NIGHTS: AME(LAST.FIRST) PHONE N WITH AREA COOS NIGHTS: NAME(LAST,FIRS <br /> _srzz- r/ i �/- <br /> PHONE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME rhar1 _ RAAL4 1O CARE OF ADDRESS INFORMATION <br /> MAILING OR <br /> STREET ADDRESS C ✓ boybhxiktle INDIVIDUAL = LOCALAGENCY STATE-AGENCY <br /> COflPOF1APON INDIVIDUAL <br /> Q COUNTY.AGENCY FEDERAL.AGENCY <br /> CITY NA E iq STjai� ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEINNER r CARE OF ADDRESS INF RMATION <br /> MAILING MST ET AD�DAREES�SA,' ///�^ - ✓ boa 0ale 0 INDIVIDUAL Q LOCAL AGENCY O STATE-AGENCY <br /> E-1 CORPORATION [v]R/RTNERSHIP Lj COUNTYAGENCY FEDERALAGENCY <br /> CITY NAME iSTgTE ZIP CODE PNONEa WITH AREA CODE <br /> /—rf/�1 A a ow <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ L4L rd <br /> 1O��S/1,? St <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ w roiiMicale I SELF INSURED 2 GUARANTEE L] 3 INSURANCE 4 SURETY BOND <br /> i� 5 LERER OF CREDIT 6 EXEMPTION OTHER Q( CO <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless boxo-o II is checked <br /> CHECK ONE BOX INOICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L O II.0 III.� <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLIC NTS T 8SI ATURE) . APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY IT JURISDICTION FACILITY# <br /> LOCATION CODE OPTIONAL iCENSUSTRACTN -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL rr <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORMS,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12a Dn FILE THIS FORM WrrH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA R6 <br />