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'##oun # <br /> STATE OFCALIFORNIA `s <br /> STATE WATER RESOURCES CONTROL BOARD ��. - o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A `� �s <br /> o. ,• o <br /> I� COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY C1 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM J 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DB/J��FACILITY NAME Mo� ^ NAME/JF OPE TOR <br /> AZZ r LCL' ' D L, NE/rygLElw.#S!T&1`fIBO$S$TRRE`ETEET•//'1 PARCEL#(OWgNAL) <br /> 9Mt <br /> CITY NAIJE � - - STATE ZIP CODE MTEP E x WITH AREA CODE <br /> �VtT(ow CA I <br /> BOX <br /> �7/LJ <br /> TOINDICATE O CORPORATION O INDIVIDUAL PARTNERSHIP E__1 LOCAL-AGENCY E-3 COUNfV#GENCY D STATE-AGENCY <br /> DISTRICTS O FEDERALAGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION Z <br /> O 3 FARM O 4 PROCESSOR O S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) /� e NE#WITH AREA COD DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAM T, IPSO C P/HONE#WITH AREAx'CODE NIGHTS: NAME(LAST,FIRST) A WITH AREA CODE <br /> PHONE 9 VtTH AREA COOP <br /> ll. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bmdkak INDIVIDUAL LOCAL-AGENCY INSTATE-AGENCY <br /> /Oy p�11[ff- _ CORPORATION O PARTNERSHIP 0 COUNTYAGENCY FEDERALAGENCY <br /> CITV � V <br /> STAT ZIP CO PHONE i WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) �7J— /q <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADD-ESS ✓ box bindicab D INDIVIDUAL D LOCAL AGENCY (]STATEAGENCY <br /> CORPORATION = PARTNERSHIP 0 COUNTYAGENCY FEDERALAGENCY <br /> CITYN ME STATf4 ZIP CODS PHONE A WITH AREA CODE <br /> BE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBERR- 932 <br /> Call(916)323-9555 if questions arise. <br /> TY(TK) HO ;4� -�1�� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bor blMicata 1 SELF INSURED r] 2 GUARANTEE I� 3 INSURANCE 4 SURETY BOND <br /> 5 LETTEROFCREDIT L�6 EXEMPTION C] W 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.0 II.X <br /> Ill.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND C RRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION it <br /> LOCATION CODE OPTION <br /> 3 r Z2 o <br /> AL .CENSUS TRACT# �OPTIONAL SUPVISOR- ISTRECTCOGE-OPTIONAL <br /> THIS F RM 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(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM33A R6 <br />