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Y�bo a e <br /> STATE OF CALIFORNIA <br /> s <br /> .. STATE WATER RESOURCES CONTROL BOARD 3,�� a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A �,o �., o' <br /> t � C�II�OYY,� <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARICONLY D 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E_] 7 PERMANENTLY SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE 6 <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FAC LITY NAME NAME OF OPERATOR <br /> F/JP.yrS0461 <br /> ADDRESS NEAREST CROSS STREET PARCEL 9(OPTIONAL) <br /> �l k1G� ,eoA� <br /> CITY NAME STATE ZIP CODE ITE PHONE x WITH AREA CODE <br /> TOIN Box CORPORATION INDIVIDUAL 0 PARTNERSHIP DGTRICTSENCV 0 COUNTY-AGENCY STATE-AGENCY 0 FEDERAL AGENCY <br /> TYPE OF BUSINESS 0 1 GAS STATION 2 DISTRIBUTOR0 RESERVATION.1IFINDDA #OF TANKS AT SITE E.P.A. I.D.#Np#o:ap <br /> 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS ' <br /> E ERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) _ •� ( ' i63 6 I3_2,7 <br /> L�NIG7HTS: NAME5" <br /> NIGHTS: NAME(LAST,FIRST) !PHONE#WITH A EA CODE (LAST,FIRST) <br /> �• Czx,] 74 — Zl Z �� PWQNP-WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NA555555C- , CARE OF ADDRESS INFORMATION <br /> /40 <br /> MAILING ORSTREETADDRESS ✓ box bWless INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> ��� O CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> __r_1k � STATE• 21P CODE 46 ONE S WITH EA CODE� <br /> v11 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAMEQFOWNER / CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ WXIDMNala O INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> t 0 CORPORATION 0 PARTNERSHIP D COUNTYAGENCY O FEDERAL AGENCY <br /> CITY NAME STATE�( ZIP CODE P ONE:WITH AREA CODE <br /> IV.B OF EQUALIZATION ORAGE FE CCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> T TK) HQ [4 74 Al <br /> V. PETROLEUM UST FINANCIAL RESPONSIBIL (MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box biMicak 0 1 SEURNSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY SONO <br /> 0 5 LETTER OF R 0 6 EXEMPTION 0 IN OTHER <br /> VI. AL NOTIFICATIO ILLING 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 11.[-7] 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 MONTWDAWVEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL If /`V �/ <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) / FOR6073A5 <br /> z <br />