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• STATEOFCAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD* <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A <br /> !� L5MTH1S FORM FOR EEA,,C�H.FACILffYISfTE \� <br /> MARK ONLY 7i m PE MR IT F7 3 RENEWAL PERMIT \ 5 CHANGE Of INFORMATION 7 PE AN Y CL=SFp S <br /> ONE REM ,<::1 2 INTERIM PERMIT F7 A AMENDED PERMIT [n',e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS,-(MUST BE COMPLETED) / <br />,! <br /> DSA O FACILITY NAME NAME OF OPERATOR <br /> Irl L;Z47 ' /I1` +Li -k%A/ <br /> .I ADDRESS 1' ' ) / 7�xf/ NEARESTCROSS STREET PARCELA(OPfgNAq <br /> A. <br /> ZI) <br /> CITY NAME STATE ZIP SITE PHONE A WITH AREA CODE <br /> \ /CA 7 �✓ �Z S'/ SCJ <br /> TO aox Q CORPORATION Q INDIVIDUAL Y PARTNERSHIP LOCAL-AGENCY Q COUNTY,GENCY Q STATE-AGENCY Q FEDERtLAGENCY <br /> ✓TS IF!NOIAN j#OF TANKS AT SITE E.P.A. L D.A <br /> TYPE OF BUSINESS 1 GAS STATION a 2 0 RESERVATION <br /> Q 3 FARM ROCESSOR 0 5 OTHER OR TRUST LANDS 2 <br /> I EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optimal <br /> i DAYS: NAME(LAST.FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> PHONE A WITH APPA ming <br /> NIGHTS: NAME(LAST.FIRST) PHONE 3 WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> PHONE A WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME I CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Sn eilmnu Q INDIVIDUAL Q LOCAL AGENCY [-..�STATE AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEOEPALAGFW <br /> Jy� CITY NAME STATE ZIP CODE I PHONE A WITH AREA CODE <br /> 1 <br /> ! III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> ! NAME OF OWNER <br /> CARE OF ADDRESS INFORMATION <br /> I MAILING OR STREET ADDRESS INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGE, <br /> Q CORPORATION Q PARTNERSHIP Q COUNTYAWJCT Q FEDEMLW <br /> CITY NAMEiSTATE ILP CODE PHONE+WITN AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323.9555 it questions arise. <br /> j TY(TK) HQ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> w <br /> ✓ e » Q I SE16URED Q 2 GUARANTEE Q 3 INSURANCE A SURET <br /> I Q S LETTER OF CREDR Q A EXEMPTION Q W 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 INOICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLWG: L IL III. <br /> I <br /> I <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 B SIGNATURE) APPLICANTS TITLE GATE MONTWDAYN R <br /> I ` <br /> LOCAL AGENCY USE ONLY L/ // <br /> COUNTY# JURISDICTION k I XCILITY x <br /> iLOCATION CODEOlAL IyT"TRACT# OPTIONAL SUWISOR-DISTRICT WDE -OPT NAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS TTnTrj*CMGE OF SITE INFORM/ <br /> FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />