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STATE OF CALIFORNIA ,� s, <br /> STATE WATER RESOURCES CONTROL BOARD w a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A gn <br /> C m> . <br /> ,.ons,. <br /> COMPLETE THIS FORM FOR EACH FACILITVISITE <br /> MARKONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NA NAME OF OPERATOR <br /> 1 \ <1 PARCEL#(OPTIONAL) <br /> ADDRESS NEAREST CROSS STREET <br /> G ' <br /> CITY NAME STATE ZIP CODE S E PHON #WITH AREA CODE <br /> Im a✓� c CA 53 Zoo a39- od65 <br /> ✓ Box <br /> TO INDICATE CORPORATION D INDIVIDUAL U PARTNERSHIP LOCAL-AGENCY <br /> (] COUNTY AGENCY STATE AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 3 GAS STATION 2 DISTRIBUTOR ❑ R SERVATION #Of TANKS AT SITE E.P.A. I.D.#(optimal) <br /> O 3 FARM 4 PROCESSOR [BOTHER 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) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA COnF <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME Q CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓Sox 0Indbal# = INDIVIDUAL I� LOCAL-AGENCY O STATEAGENCY <br /> d J f'I L V E-1 CORPORATION ?TPARTNERSHIP D COUMYAGENCY O FEDERAL-AGENCY <br /> CIN NAME STAT ZIP CODE HO E#WITH AREA CODE <br /> q �a r'�fso7 63— ,�63 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Sgrv�L a S <br /> MAILING OR STREET ADDRESS ✓ box bindicM O INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION (] PARTNERSHIP 0 COUNTY-AGENCY D 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 bindicale [__1 1 SELF-INSURED [_:1 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> = 5 LETTER OF CREDIT F-1 6 EXEMPTION 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 c cked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II. 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 NAM E(PR INTED&S IGNATU RE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> � !, <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> z6 X23-9z <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 /> FORMA(5-91) <br /> FOR0033A 5 <br />