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o e <br /> STATE OF CALIFORNIA % <br /> J STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACO FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ]]] <br /> DBA CILI�NA� NAME OF OPERATOR <br /> ADDRESS ^ NEAREST CROSS STREET PAACEL#(OPHONAL) <br /> CITY NAME G /J\ STATE ZIP CO E SITE P NE#WITH AREACODE <br /> o� CABOX <br /> Z�fb 3 <br /> TOINDICATE O CORPORATION O INDIVIDUAL E::] PARTNERSHIP O LOCAL-AGENCY COUNTY AGENCY O STATE-AGENCY [:D FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTORO ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR 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 /> NIGHTS: NAME(LAST.FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA GOOF <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED <br /> 44 1 CARE OF ADDRESS INFORMATION <br /> MAILING OgR STREET ADDRESS) r-, ✓ box ho MIcale O INDIVIDUAL 0 LOCAL-AGENCY —1STATE-AGENCYZ�/ /yyy/ /�D JAL • =CORPORATION O PARTNERSHIP Q COUNTYAGENCY Q FEDERAL-AGENCY <br /> CITY N ME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 44--f/- D <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER I A CARE OF ADDRESS INFORMATION <br /> EETAODRESS ✓ WxbiMkate D INDIVIDUAL OLOCAL-AGENCY (] STATE-AGENCY <br /> 3797 •^r •/ =CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITU N ME � ? STATE# ZIP COD PHONE#WITH AREA CODE <br /> IV. BOARD OF EE/ -- <br /> QUALIZATION UST STORAGE FEE ACCOUNT NUMBER t—Call(9196)'3723'-9555 if questions arise. <br /> TY(TK) HQ L47 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to Wicale 0 I SELF INSURED 0 2 GUARANTEE 3 INSURANCE 0 4 SUREN BOND <br /> t� 5 LETTER OF CREDIT 6 EXEMPTION 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.❑ II.❑ 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 Lf(o34k <br /> COUNTY# JURISDICTION# FACIIEX- — <br /> LOOOON CODE �OPTIONAL CEF511.ACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> Z3. 7 � ET <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF ITE INFORMATION ONLY. <br /> FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOROW3AP6 <br />