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'QpOVa <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD w mom! ss <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> ';f <br /> COMPLETE THIS FORM FOR EACH CILITYJSITE <br /> MARK ONLY <br /> O 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERM ENTLV ol.Oc <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA �LITYNAME .�^�'x / NAME FOPEQ BATOR_ ^'j" ,^N / <br /> RR//�nJJ CC {if 4a c IILNAe-�i.. ''��/ IY N <br /> ADDRESS S /` � Rd, NEAR STC GREET �A/� $/PIAfl�CEL c(I�0`PFIOI.N�Ay <br /> CITY NAME^ \J ,/l / STATCxEAr/D~ ZIF 0(AJ�,.•,I�V7�`V� {Y`D (E J H AEA COD <br /> ✓ BOXCORPORATION �INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY Lj COUNTY-AGENCY LDSTATE-AGENCY (O FEDERAL-AGENCY <br /> TO INDICATE DISTRICTS V IF INDIAN <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR 0 RESERVATION x OF TANKS AT SITE E.P.A. I.D.#(opfionalJ <br /> 3 FARM O 4 PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: (LAST FTS') ^ PHON %WITH RE CODE+q� DAYS.�AME(LAST,FIRST) (:Ti dao G / <br /> ft <br /> a r <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WIT BEA�(/CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRESS \ ✓ box b"N"cate O INDIVIDUAL 0 LOCAL-AGENCY STATE AGENCY <br /> T D CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BKOMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to Indicate [_1 INDIVIDUAL LOCAL-AGENCY =1 STATE-AGENCY <br /> CORPORATION = PARTNERSHIP L] COUNTY-AGENCY O FEDERAL- <br /> AGENCY <br /> CITY NAME ti STATE I ZIP CODE I PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCO NUMBER-Call(91 6)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - 1 1� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECO LETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boxbintlicale [71 1 SELF INSURED 2 GU EE 0 31NSURANCE 4 SURETY BOND <br /> =5 LETTEROFCREDIT fi E%EMP ON O W 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O IL❑ It. <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 B SIGNATURE) APPLICANTS TITLE DATE MONTWDAVPIEAR <br /> LOCAL AGENCY USE ONLY 0 hG <br /> COUNTY# JURISDICTION# FACILITY# <br /> In 1 11 17R7 <br /> LOCATION ODE -OPTIONAL CENSUST # -OPTIONAL� SUPVISOR-DIOPTIONAL <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 /> /i <br /> y�d D"J' e /5� ,n FOR0033A-5 <br /> lel D� l SSGt 2 �2 CJcam• _c� - 4/3 <br /> `� <br />