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STATE OF CALIFORNIA t "- <br /> 9 <br /> STATE WATER RESOURCES CONTROL BOARD 3 ., <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A Q <br /> COMPLETE THIS FORM FOR EAcqFAciLrTYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT If 5 CHANGE OF INFORMATION 7 PER Y CLOS ITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE (�� <br /> 1. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF:OPERATOR <br /> 'e- Q <br /> ADDRESS � /� NEAREST CRW STREET <br /> PARCEt#IOPTIONALI <br /> CITY NAME STACE� ZIP CO E _ wE PCO E#WISH-ACODF <br /> tall 7� <br /> ✓ BOX <br /> TO INDICATECORPORATION INDIVIDUAL Q PARTNERSHIP [] LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY F7 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN 1,1 OF TANKS AT SITE I E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM r__j 4 PROCESSOR Q 5 OTHER 01; <br /> TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAS: AME(LAST,FIR PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGH S: NAM {L T,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA Conr: <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME r CARE OF ADD SSpINFORMA71A le <br /> 62 J I t <br /> MAILING OR STREET ADDRE S ✓ box to InOICat8 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> 4 ' W <br /> CORPORATION [] PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> Gil TY ME ST61E ZIP CODE PH NE#WIT A A ODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indkate INDIVIDUAL 0 LOCAL-AGENCY L__I STATE-AGENCY <br /> CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZVP 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 147141- <br /> V. <br /> 4 -V, PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box*indicale p 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 0 A SURETY BOND <br /> L-1 5 LETTER OF CREDIT 6 EXEMPTION I7 99 OTHER <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 /> [CHECKONF BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ I. 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&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# , <br /> � ` I I IlIql(olai <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OFSR ORM ION ONLY. <br /> FORM q(5-91) FOR0073A- <br />