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STATE Of CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ,p � .0 <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY W PERMIT � 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY <br /> ❑ S NEW � 0 <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME ! NAME OF OPERATOR <br /> '' f,'�=- ��1 r,<r�-'- � � L,�I � 1 S L� ,�►'I f r`t <br /> ADDRESS i NEAREST SS STREET PARCEL#(OPTIONAL) <br /> 4 <br /> CITY NAME 1 STATE IP CODS .i SITE PHONE#WITH AREA CODE <br /> CA <br /> BOX <br /> TOINDICATE Q CORPORATION Q INDIVIDUAL © PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ; ' GAS STATIN Q 2 DISTRIBUTORQ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D-#(optional) <br /> RESERVATON �r <br /> r7 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS _ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A NTH AREA mop <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH ARELQQU_ <br /> ll. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME r1 +} CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS' r 1- ✓ WXka44cate (Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Z` —2j irJ C +i I ,f J Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STr. ZIP COIF PHONE#WITH AREA CODE <br /> �7 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box 10Odieate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indkata Q I SELF-INSURED ® 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> Q 5 LETTEROFCREDT Q 6 EXEMPTION Q 99 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 /> E <br /> CK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: t. II. III. <br /> THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHJOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> EE <br /> LOCATION CODE •OPTIONAL CENSUS TRACT* -OPTIONAL SLJPVISOR-DISTRICT E -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) FOR0033A.5 <br />