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STATE OF CALIFORNI A <br /> STATE WATER RESOURCES CONTROL BOARD iy o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> y- <br /> 0 <br /> COMPLETE THIS FORM FOR EACHLPcurYISTTE <br /> MARK ONLY I NEW PERMIT j ] RENEWAL PERMIT S CHANGE OF INFORMATION El ) PERMANENT SED SUE <br /> ONE ITEM hI 2 INTERIM PERMIT O l AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION S ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME /� NAME OF OPERATOR <br /> 1'v Ick- 1_^) �- [/JI <br /> ADDRESS Igin ���� / NEAREST CROSS STREET PARCELA(OPTONAL) <br /> CITU NAMEv BOX STATE ZIP CODE 2� $ITE PHONE.WITH AREA COp �� <br /> TOINpCATE O CORPORATION C INDIVIDUAL PARTNERSHIP LOCAL-AGENCY DISTRICTS 0 COUNTY-AGENCY <br /> O STATEAGENCY �J FEDEML-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS I GAS STATION u 2 DISTRIBUTOR I = ✓ IF INDIAN •OF TANq <br /> RKS AT SITE E.P.A. L D.A(wIwv <br /> ESERVATION <br /> Q 3 FARM < PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAM LAST,FIRST) e PHONE s WITH AR ODE DAY NAME(LAST,FIRST) — <br /> NIGHTS: NAME(LAST,FIRS lM PHuNe AWITH AREA CODE NIGHTS: NAMMEEJLA�II. RST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> '\ <br /> OP-5hr1 �zu vtG c, <br /> V (LING OR STREET ADDRESS ✓ m,btr9i�u INDIVIDUAL I� LOCAL-AGENCY �' STATE-AGENCY <br /> Z Q Q CORPORATION PARTNERSHIPCOUNTY-AGENCY FEDERAL#GENCY <br /> CIT/'NAME G 7vh STAT ZIP CODE Zo/ I PHONE t WITH AREA CODE_ <br /> III. TANK OWNER INFORMATION- (MUST BE COMPLETED) 97 <br /> NAME OF OWNER n^ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS - ✓ mibmOcaO = INDIVIDUAL G LOCAL AGENCY Q STATE-AGENCY <br /> O CORPORATION Q PARTNERSHIP L'–] COUNrY-AGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 44 -�J L Q171ZJ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ m,bNvI.% = I SELF-INSURED ,'1_, 2 GUARANTEE 0 3 NSURANCE 1 SURETYBOND <br /> = 5 LETTER OF CREDIT Ej 6 EXEMPTION Q N OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner Unless box I or IIsked. <br /> CHECK ONE BO%INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L= 11. IT. <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 A S)GNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COms ZJ&5'2� JURISD�ICTIIOON a FACILITY x <br /> LOCATION CO TIUNAL ICE/N/SUS TRAC$,,^OP TONAL SUPVISOR-DISTRICT CODE -OPTCNAL <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(591) <br /> FORD A5 <br />