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• • OJR [. <br /> STATE OF CALIFORNIA <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD �� o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �� v¢ <br /> OnM <br /> COMPLETE THIS FORM FOR EACH CILRYISITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT E-]/CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT fe a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORF ILITYNA NAM ERATOyI <br /> AD R 2 � a� ' - i� NE CROS T-REET PARCEL#(OPTIONAy <br /> CLJ� V i <br /> CITU M STATE ZIP C SITEPHONE#WITHAREACODE <br /> ✓ BOX CA <br /> TO INDICATE E-�]CORPORATION O INDIVIDUAL Q PARTNERSHIP LOCAL AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR -/ IF INDIAN #OF TA S AT SITE E.P.A. I.D.#(optional) <br /> ❑ RESERVATION <br /> O 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(L AST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boa toladkat# E�:] INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY [—I FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS- ✓ box bkMkate E-j INDIVIDUAL Q LOCAL AGENCV (]STATE-AGENCY <br /> 0 CORPORATION Q PARTNERSHIP 0 COUNTY-AGENCY E--1FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 L]- <br /> NA <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP D)—IDENTIFY THE METHOD(S) USED <br /> ✓ w roindkala F] I SELF INSURED 0 2 ARANTEE 0 3 INSURANCE [-14 SURETY BOND <br /> 5 LETTEROFCREDIT 44 EXEMPTION El 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.❑ IL❑ III.❑ <br /> THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED B SIGNATURE) APPLICANT'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# URISDICITION# FACILITY# .... _.-- J17=1214 -19 <br /> 94 <br /> LOCATIO OpE -OPTIONALCENSUs TRACT#g/jTjByALSUPVISOR-DISTRIC 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(12-91( FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UUUNNDDEE/RGG{R�ROODUNNJD STORAGE <br /> ���� <br />