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STATE OF CALIFORNIA eyow e <br /> STATE WATER RESOURCES CONTROL BOARD ° c <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> s D <br /> COMPLETE THIS FORM FOR EACH FACILRY/SITE a ��"`°"��"'�. <br /> MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ONE ITEM PERMANENTLY CLOSED SITE 2 INTERIM PERMIT Ej q AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 8 ADDRESS-(MUST BE COMPLETED) Z <br /> DBAORFACILITY AME <br /> G� NAMEOFOPERATOR <br /> ADDRESS �O <br /> //b A.- NEAREST CROSS STREET PAgCELYIOPfggqq <br /> CITY NAME/ !/i� <br /> STATE ZIP CODE <br /> ✓ Po% �� CA �5_ _ /U SITE P NE#WITH AREA Cp <br /> GLf �►"P X69 - ��i <br /> TO INDICATE ID COBPOIiATION ID INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY <br /> DSTRICTS 0 COUNTY-AGENCY $TATE-AGENCY <br /> TYPE OF BUSINQ FEDERAL#GENCY <br /> ESS O I GAS STATION O 2 DISTRIBUTOR <br /> Q O ANOA <br /> TANKS AT SITE E.P. . L D.#opl/anal/O q PROCESSOR RESERVATIOOF <br /> 3 FARM OTHER R <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> DAYS: NAMEFIRST) <br /> NIGHTS:: NNAAMMh(`LAA r,,GFIRST) 'P'HOINEA WITH/AREA CODE <br /> NIGHTS: NAME(UST,FIRST) <br /> II. PROPERTY OWNER INFORMATION•JMUST BE COMPLETED <br /> NAME <br /> ME CAREOFAODRESSINFORMATION <br /> MAILINGOR STREET gpDRESS L box bindkale <br /> jJ ,G�jO O INDIVIDUAL O CLOCAL-AGENCY O STATE-AGENCY <br /> CITY NAME O <br /> CORPORATIONQ PARTNERSHIP D COUNTY (] FEDERAL-AGENCY <br /> �d D STATE ZIP CODE PONE xyVITH AREA UUUE� <br /> G,A— �-i5• v Jl 7/ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> [�MA <br /> E OF OWNER <br /> �/]�' � CARE OF ADDRESS INFOflMATION <br /> ING Oq STREET ADDRE/ 11 INDIVIDUAL � LOCAL-AGENCY Q STATE-AGENCY NAME - — — L7 CORPORATION <br /> I� PARTNERSHIP �COUMY.IGENCY 0 FEOERALdGENCY <br /> �a�Z STA�TE� 21P CODE HONE# ITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER all(9166-9555 if questionsar� <br /> TY(TK) HQ L Q - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box blMicale [] I SELF INS O 2 GUAgAMEE <br /> 5 LETTER OF CREDIT6 EXEMPTION � 3 INSURANCE O4 SURETY BOND <br /> 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 cliecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> I.E-] II. 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(PgINTED 8 SIGNATURE) <br /> APPLICANTS TITLE DATE MONTWOAy/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> _ i L 1 -5- <br /> LOCATION CODE OPTIONAL ICENSUSTRACT# -OPTIONAL <br /> `jT— 23 < ISUPVISOR-DISTRICT CODE -OPTIONAL <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 Ilz 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> • • e FOR0033A.16 <br />