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• � S��A <br /> STATE OF CALIFORNIA =P'` <br /> STATE WATER RESOURCES CONTROL BOARD w.� At o <br /> C � UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH fTYfS17E <br /> 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANEN CLOSE SITE <br /> MARK ONLY <br /> ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITYISITE-IN-156RMATION & ADDR pMPLETED) <br /> ME OF OPERATOR <br /> DBA OR ILITY NAM A/ tJ ' <br /> k1 12 , [ l �^ REST GROSS STREET <br /> - PARCEL R(OPTIONAL) <br /> tSf= <br /> ADDRESS - rf <br /> f `�S S0��'�'C t STAZIP CODE SITE PHONE x WITH AREA COO; <br /> TE <br /> CITY NAM; I CA 4z Z C _ y / — Y 3 <br /> TO INDICATE 0 CORPORATION ©INDIVIDUAL Q PARTNERSHIP LOOS AL.AGENCY Q COUNTY-AGENCY Q STATEaAGENCY FEBERAL•AGENCY <br /> RICTS ✓ IF INDIAN x OF TANKS AT SITE E.P.A. I.D.aI foprional) <br /> TYPE OF BUSINESS 0 1 GAS STATION 2 DISTRIBUTOR = RESERVATION <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> PHONE 0 WITH,AgE G E DAYS: NAME(LAST,FIRST) <br /> DAYS: NAME{LAST,FIRST) G rVW ARE A.rOOE <br /> NIGHTS; NAME(LAST,FIRST) PHONE w WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> --r IMITU AQ <br /> Il. PROPERTY OWNER INFORMATION• MUST BE COMPLETED j CARE OF ADDRESS INFORMATION <br /> NAME <br /> ✓ box 10041cate 0 INDIVIDUAL [ 'LOCAL-AGENCY 9] STATE-AGENCY <br /> MAILING OR STRE T ADDRESS <br /> J � C fry G 0 CORPORATION = PARTNERSHIP []COUNTY-AGENCY FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE N WITH AREA CODE <br /> CITY NAME J/ 01 1, Y �' <br /> NI. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION. <br /> NAME OF OWNER <br /> MAILING OR STREET ADDRESS ✓ box n indicate Q INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> [�CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE s WITH AREA CODE <br /> CITY NAME fes` <br /> 1Y. BOARD OF EQUALIZATION 1ZATION U GE FEE ACCOUNT NUMBER-Call(916)323-9555 if quesfaonS arise. <br /> TY(TK) HQ 4 4 - t{ d <br /> V. PETROLEUM 10ST FINANCIAL 6PONS, ,)LrTY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> t SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> ✓ boxriindCate <br /> 5 LEITEROFCREDIT =6 EXEMPTION 99 OTHER <br /> 0 <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK DNE a0%INDICATING W}31CH ABQVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> ,.fl II.= III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED& <br /> APPLICANTS TITLE <br /> SIGNATURE) DATE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT o -OPTIONAL <br /> SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPL1CATlON- FORM B,UNLESS THIS IS A CHANGE Of SITE INFORMATION FOROD3ONLY;A 5 { <br /> FORMA(5-91) <br />