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' :t <br /> STATE OF CAUPORMA Ate! ac <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM A c.�,aFY`'-> <br /> COMPLETETHIS FORM FOR EACH FACILITYISRE Bar <br /> /7 O S OF INFORMATION Q 7 PERMANENTLY CLOSED B� z <br /> 0 1 NEW PERMIT 3 RENEWAL PERMIT <br /> MARK ONLY � AMENDED PERMIT TEMPORARY SITE CLOSURE <br /> ONE ITEM Q 2 INTERIM PERMIT <br /> I. FACILITYISITE INFORMATION dI ADDRESS-(MUST BE COMP NAME OF OPERATOR / <br /> DRAOR FACILITYNAME r PARCELA(OWIONAII <br /> ' 1 NEAREST CROSS STREET <br /> " sy � . H, l9e . <br /> STA TE ZIP CODE SITE PHONE e W LTH AREA LADE <br /> CITY NAME_ CA <br /> S Y. OSE <br /> ,/ BD% O CORPORATION Q PARTNERSHIP LOCAUAGENCV #GBN:Y' a <br /> FEI ERAL#GENCY' <br /> DISTRICTS' <br /> TO INDICATE :nAms d dNYbn.se0ion,or oRla hitch OPEN the UST <br /> .P owner d UST le a Padb aBenoY•mna°U Ns d SupeNbpr �/ INOIAN a OF TANKS AT SITE E.P.A. I.D.a(oPrwlep <br /> TYPE OF BUSINESS O T GAS STA N Q 2 DISTRIBUTOR SERVATION <br /> Q 7 FAR Q 4PROCESSOR 5 OTHER TRUST ANDS <br /> L <br /> EMERGENCY CONTACT PERSON (SECONDARY)-bptlona <br /> EMERGENCY CONTACT PERSON (PRIMARY) .NAME(LAST,FIRST) PHONE e WIT A CODE <br /> DAYS: NAME(LAST.FIRS P e WITH ARE CODE I .` <br /> G b O a PHONE e. TH AREA CODE <br /> BC)S <br /> PHONE a WIT AREA NIGHTS:NAME(LAST,FIRST) � <br /> NIGHTS: NAME(L T.FI ST) <br /> II. PR ERTY OWNER INFORMATION• MUST COMPLETED CA___F ADDRESS INFORM TON;\ D <br /> NA E I+D� <br /> box tWkAa E-1 INDIVIDUAL A4AGENCV O STATE'AGENCY <br /> MAIL O STP ET ADDRESS CORpORATION Q PARTNERS COUNTY#GENC1' 0 FEDERAL#GENCY <br /> STATE ZIP CODE IIIONE LTH AREA CODE <br /> CITY <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) CARE OF ADDSES FORMATION j <br /> NAME OF OWNER ATE-AGENCY <br /> S V borbi O INDIVIDUAL O LOCAL AGENCY I� F HAL-AGENCY <br /> MAILING OR STREET ADDRESS 0 COR RATION CDP ARTNERSHIP Q COUNTY#GENCY <br /> STATE/ zip CODE PHONE a WIT EA CODE <br /> CITY NAME % <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions ari <br /> TY(TK) HQ 4 4- <br /> Ef <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MU S7 BE COMPLETED)—IDENTIFY THE 3 Imu.HOD(S) USED 0 A SURETY BOND <br /> O 1 SELF INSURFD ED 2 GUARANTEE gg OTHER <br /> '�bor bbdkNe 5 LETTEP OF CREDn O e EXEMPTION <br /> ADDRESS ' Legal notification and billing will be sentto the tank owner unless box I or II is checked. <br /> VI. LEGAL NOTIFICATION AND BILLING <br /> H. uI. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BIL G: I'0 <br /> THISRECT <br /> PEFUURY,AND TO THE BAT OF MY KNOWLEDGE,IDSA TRUE AMSC W�pp <br /> FORM HAS BEEN COMPLETED UNDER ONALTY OF <br /> rNEAa <br /> OWNER'S TiT <br /> OWNER'S NAME(PRINTED 6 SIGNED) /. <br /> LOCAL AGENCY USE ONLY / <br /> COUNTY a JURISDICT r <br /> S TRACT i - SLMvISoR-DISTRICT <br /> ODc/ooh �� <br /> LOCATION CENSU <br /> -OPTIONAL S <br /> LEAST(1)Ofl MTHiE PERMIT APPUCATI0N- FORM B,UNLESS THIS IS A CHANGE OF SITE IIFORtIIATKN+ONLY. <br /> TWS FORM MUST BE AHED BY AT wa1� <br /> OWNER FILE THIS FORM WRN THE LOCAL AGENCY WLEMEIITING THE UNDERGROUND STORAGE TAN(REGULATIONS <br /> I PO <br /> /U <br />