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• • 'L60VN : CV <br /> STATE OF CALIFORNIA ^e <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> ` / C�IIROFMn <br /> C/ COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> r T/ - !gyp <br /> ADDRESSn' (� NEAREST CROSS STREET PARCEL N IOPTIONAW <br /> CITU NAMEO� / STACT/EA ZI ITE PHQNE#WITH AREA CODE <br /> G 5 <br /> TO INDICATE O CORPORATION [71 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY Q STATE-AGENCY FEDERAL.AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ t GAS STATION 2 DISTRIBUTOR / ✓ IF INDIAN NOF®KS AT SITE E.P.A. I.D.#(aptbnaQ <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION <br /> ❑ ❑ OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) HONE#W WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> O /? DR) 399--- Si/7 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME— //''�� �'`p� CARE OF ADDRESS INFORMATION <br /> ce— <br /> MAILING OR STREET ADDRESS ✓ box 0Indicate I= INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> D �jQ I Z1 �CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY L= FEDERAL-AGENCY <br /> CITU NAME STATE ZIP <br /> CODE // ONE,#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box ioindicaux INDIVIDUAL Q LOCAL-AGENCY �STATE-AGENCY <br /> 'y 0 CORPORATION PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZI HONE N WITH AREA CODE <br /> 'e/' <br /> Pp <br /> � °Ci <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQF4 F4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY- (MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box 0indicate —1 1 SELF-INSURED [—]2 GUARANTEE [::]3 INSURANCE Q 4 SURETY BOND <br /> 5 LETTER OF CREDIT L-1 6 tx ION Q 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: L❑ IE 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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ©6s> /f <br /> LOCATION CODE -OPOf <br /> TIONAL CENSUS MACT# -OPTIONAL SUPVISOR-DISTRICT CODE-OPTIONAL �•. /� <br /> THIS FO MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATI ONLY. <br /> FORMA(5-91) a <br />