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• • .e'�.- a ce <br /> STATE OF CALIFORNIA �? <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE SITE <br /> ❑ 1 NEW PERMIT <br /> ❑ 3 RENEWAL <br /> MARK ONLY PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANE U <br /> ONE ITEM ❑ 2 INTERIM PERMIT <br /> ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION& ADDRESS-(MUST BE COMPLETEDEOF OPERATOR 11 <br /> S <br /> DBAOR FACILITY NA E c` f �• PTq <br /> 1 NEAREST CRO SSTREET PMCELp(OFrIONAq <br /> ADDRESS ' CZI' Q ✓I L ZIP DE LJ PHONE WITH AREA CODE <br /> STATE <br /> CITY NAME C A <br /> TO INDICATE E 0 CORPORATION 0 INDIVIDUAL =PARTNERSHIP LOCAL-DISTRIAGENCY COUNTY AGENCY 0 STATE AGENCY EDEML-AGENCY <br /> ✓ IF INDIAN %OF TANKS AT SITE E.P.A. I.D.#01)IIwal1 <br /> TYPE OF BUSINESS 1GAS STATION ❑ 2DISTRIBUTOR = RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR gfETHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> PHONE%WITHAREACODE DAYS: NAME(LAS T.FIRST) bs5/- �j 9'/'DAYS' NAME(LAST,FIRST) 15s 1-1-6 <br /> /J / p <br /> v0� ` PHONE%WITHAREA CODE NIGHTS: NAME( T.FIRST) 0U <br /> NIGHTS: NAME( S'T F ST) 556 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE 0 ADDRESS INFORMATION - / 74-7-fNAME �I G ��7'q <br /> U,- S• OV . ✓btbIn kale INDIVIDUAL 0 LOCAL-AGENCY [_j STATE-AGENCY <br /> MAILING OR STREET ADDRESS <br /> ,qL000RPORATION PARTNERSHIP 000UNTY-AGENCY FEDERAL-AGENCY <br /> STATE ZIP CODE -,=/,-7 •�2Of � JO WITH <br /> CITY NAME S <br /> ODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> ENAMF OWNER <br /> TI� ✓ boxblMicaw 0 INDIVIDUAL 0 LOCAL'AGENCV 0 STATE-AGENCY <br /> OR STREET ADDRESS 0 CORPORA11ON O PARTNERSHIP 0 COUNTY-AGENCY FEDERALAGENCY <br /> — STATE ZIP CODE PHONE#WITE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - 4T 3 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED a suRErveoNo <br /> 0 1 SELF INSUflED D 2 GUARANTEE 0 3 INSURANCE D <br /> ✓ Ma bindkale 0 8 E%EMPTION geV OTHER <br /> D 5 LETTER OF CREDIT <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checko. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND <br /> EBILLING: <br /> ❑ n, ul.❑ <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) <br /> APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY q`t0 ,T <br /> COUNTY# <br /> JURISDICTION# FACILITY# <br /> 2 <br /> SUP VISOR-DISTRICT CODE -OPTIONAL <br /> LOCATION CODE -OPTIONAL ICrNSUS TRACT# -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(5-91) <br />