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�eaoun e U <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�L� �:° <br /> e �s.l�. o <br /> C��IiOPN�� <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 54 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBAORMTYNAMENAMEDFaOF��RA R <br /> LUI` lV (J <br /> ADDRES;?��ID /I � � NEAREST CROSS STREET PARCEL#IOPIONAII <br /> CIN NAME GG��-- V/v� STATE <br /> CA SIIFa Oy�MAREA CODE <br /> � <br /> ✓ Box <br /> G[��lJ <br /> TOINDICATE IXCORPORATION Q INDIVIDUAL I= PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY D STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(opfianal) <br /> RESERVATION <br /> 3 FARM O 4 PROCESSOR E:] 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:MLASI,FIIR T) PHONE# ITH AREA CODE 2 DAYS: NAME(LAST,FIRST) <br /> �9 3- <br /> NIGH S N TLA^T, IRII� PHONE WITH ADE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFOR ATION• MUST BE COMPLETED)/l <br /> CAROFD/S`JyFORAcNAME JN �/� vC <br /> MA//X D INDIVIDUAL LOCAL-AGENCY� <br /> STATEAGENCY <br /> �fCORPORATION = PARTNERSHIP 0 COUNTYAGENCY FEDERAL-AGENCY <br /> CITU E 1^ ^ ?T,Aq— ZIP DE: 2— pZb7/1 62.eI <br /> ttaIII. TANK 1 WNE,R (INFORMATION•(MUST BE COMPLETED) ( J, ter/ <br /> NAMEOFOWNER /� „^�^ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREVADDRESSbDX bintlkate 0 INDIVIDUAL l= LOCAL-AGENCY =STATE-AGENCY <br /> �//1 D CORPORATION = PARTNERSHIP D COUNTY AGENCY O 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 [4R1-EI7=FT-1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ boll b Indicate I SELF INSURED =1 2 GUARANTEE 3 INSURANCE E�]4 SURETY BOND <br /> (]5 LETrER OF CREDIT O 6 EXEMPTION r N 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[D 11.^ III.❑ <br /> THIS FORM HAS BEEN COMPLETED U R PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APP ICA SHAM PRI EDB SIGNATURE) APPLI '^^(TLE DATE MONTH/DAViV AR <br /> '!G�/j V V �/ <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# }coa3 <br /> LOCATION CODE -OPT/ONS/ CENSUS TRACT# -OPT/OfgAL SUP'V�ISSTRICT CODE -OPTIONAL` <br /> C/ (/Y'A'1 <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) FOR0063A-5 <br /> 0 0 <br />