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• i L`w• <br /> STATE OF CAUPORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM AA, <br /> COMPLETE THIS FORM FOR EA FACILI YISITE °•�,.,..^ <br /> MARK ONLY I NEW PERMIT 7 RENEWAL PERMIT 5 CHANGE OF INFORMATION E 7 PERMA/dEIPILY CZ"Op <br /> ONE REM 2 INTERIM PERMIT A AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) `J <br /> DBAOR FAC I NPM - I NAME OF OP RATO /�n /� <br /> ADDRESS NEAREST CROSS STREET /f/ G PARCELA(OFnDNAU <br /> CITY NAME STATE ZIP Z NEA ITH AREA CODE <br /> CA <br /> TI/ <br /> BOOX -CORPORATION 11 MNIOUAL I�PARTYGRSMP p D ISTRIisGENOY Q COUNTYAGENCY' L, STATE AGENCY' Q FEOEW.AGENCY- <br /> 'A vxner BUST ie a c,+blic agenry,mrrylae IM toeaeng:name d Superisw d avebn.feCYion,n d&s wNirJt operate tM UST <br /> TYPE OF BUSINESS I✓ I OAS STATION J 2 DISTRIBUTOR ✓ IF INDIAN S OF TAN�5.1,T SITE =P.A I.0.s fqD&*aq <br /> O FARM ;� A PROCESSOR 1— 5 OTHER OR TRUST LAJ J <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON iSECONOARY)-opilmil <br /> DAYS: NAME(LAST,FIRST) PHONE I WITH AREA CODE DAYS:NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS:NAME(LAST.FIRST) PHONE A WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> ( NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS - V' J Eoipvl9oa = INDIVIDUAL LCCAL.AGENCY _ STATE AGENCY <br /> IL L CORPORATION U PARTNERSHIP CCU.NTYAGENCY a FEDERAL AGENCY <br /> CITY NAME STATE. i DP CODE PHCN'E.A WITH AREA CODE <br /> i <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ em V n _ INDIVIDUAL LOCAL AGENCY <br /> a STATEAGENCY <br /> ' CORPORATION 1 PARTNERSHIP _ ,^.GUNNY AGFNC/ FEDERA4AGENCY <br /> CITY NAME STATE iZIP CCOE PHONE A WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HO 4 4-I 0 <br /> V. PETROLEUM UST FINANCI RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE ME-iHOD(S) USED <br /> ✓ Eo[ougicale I SELF-INSURED C 2 GUARANTEE Cj T INSURANCE A SURETY EOND <br /> 5 LETTEROFCRETxr Lr a EXEMPTION W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is checked. <br /> CHECK ONE Box INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLWCv' I._i II.= III. <br /> THIS FORM HAS BEEN COMPLE7ED UNDER PENALTY OF PERJURY,AND TO THE BEST CIF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> OWNER'S NAME(PRINTED B SIGNED) OWNER'S TITLE DATE. MCNTWOAY/YEAR <br /> i) <br /> LOCAL AGENCY USE ONLY '4 <br /> COUNTY x JURISDICTION a FACILITY s <br /> 2� n-T77 f <br /> 4 <br /> LCCATICN COOfi•-�PTTONAL (CENSUS TRACT i�TK1 O (SUPVISOR-OISTRICTCO- TA7RAL <br /> 0/1 3 f% v <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMITAPPLICATION- FORM B,UNLESS IS S A CHANGE OF SITE INFORMATION ONLY. <br /> :ORM A(199) <br /> OWNER MUST FILE THE FOPW THE LOCAL AGENCY IMPLEMENTING THE UNDERGRODUrAGE TANK REGULATIONS _ ORT7AA7 <br /> i <br />