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STATE OF CALIFORNIA • <br /> UNDERGROUND STATE WATERRESOURCES CONTROL BOARD <br /> STORAGE TANK PERMIT APPLICATION- FORM A <br /> \ w <br /> G <br /> v <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT °ar.o„oo <br /> ONE ITEM ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ❑ 2 INTERIM PERMIT ❑ q AMENDED PERMIT <br /> I. FACILITY/SITE INFORMATION&ADDRESS- T PERMANENTLY CLOSED SITE <br /> ❑ e TEMPORARY SITE CLOSURE <br /> DBA ORACILITY NAME (MUST B E COMPLETED) <br /> ADDRESS ��0VG NAMEOF OPERATOR <br /> Clry NAME NEp?Eg,T C-ROSS SigEE7 <br /> PAgCEL#OPfpNAq <br /> G(7U! �i" /4i <br /> STATE ZIP CODE <br /> ✓ BOX CA Z40,10 <br /> „/U ITE PF11�NE#WIIT�HHAREA CODET <br /> TOIF BUSIE 0 CORPORATION DIVIDUAL 1�PARTNERSHIP `l J��—( -�v <br /> TYPE OF BUSINESS L7 LOCALCGENCY COUNTY-AGENCY <br /> ❑ 1 GASSTATION ❑ DISTRICTS O STATE-AGENCY � FEDERAL-AGENCY <br /> 2 DISTRIBUTOR <br /> ❑ 3 FARM ❑ q PROCESSOR ,._� ❑ ✓ IF INDIAN #OF TANKS AT SITE E.p,p, I.D.# <br /> �J 5 OTHER RESERVATION (�II�N) <br /> EMERGENCYCONTACT PERSON (PRIMARY) OR TRUST LANDS <br /> DAYS: NAME(LAST,FIRST) EMERGENCY CONTACT PERSON (SECONDARY) <br /> PH <br /> . <br /> ,,,Tr#WIT REACODE <br /> JIJI 3 _2�D DAYS NAME(LAST,FIRST) OpilOnel <br /> NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION <br /> NAM - MUST BE COMPLETED <br /> F[L�� ,4ee J ; CARE OF ADDRESS INFORMATION <br /> MAILING O��TADDRESG ( �///'��•• <br /> 7-3 _ ,\ ✓hox to intlkale <br /> CITYNAME// � `� CORPoRATION NDIVIDUAL 0 LOCAL-AGENCY 0 STATE AGENCY <br /> A4F /LlbSi TE- 0 PgpTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> `/�/4I_ ZIP CODE <br /> PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAOFOWNEq <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> Z3 7' Af &Tort ,� ✓box blrMkao <br /> CITY NAME CORPoRgTION DIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> D PARTNERSHIP 0 COURry'AGENCY 0 FEDERAL-AGENCY <br /> /}U STATEi ZIP CODE <br /> 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 - —J�L�r rT—r TI I I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ bav n irSar D I WIN9URED 0 2 GUARANTEE <br /> O 5 LETTER OFCREDIT 0 6 EXEMPnON 1�3 3 INSURANCE O q SURETY BOND <br /> 0 99 OTHER <br /> VI. LEGAL NOTIFICATION AND RILLI114 ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECICO/E90X INDICATING WHICH ABOVE ADOW SHOULD BE USEDFoR LEGAL NOTIFICATIONS AND BILLING: <br /> I.❑ II. III. <br /> THIS FORM HAS BEEN COMPLETEDA PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE <br /> DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY III JURISDICTION# <br /> �-I-I FED FACILIY# <br /> LOCATION CODE -OPTIONAL CENSUSTI# -ppT/OA%L <br /> r/2 rJ SUPVISOR-DISTRICT CODEoz— -OpT/ONAL <br /> a ! J ;J F--r- 4z <br /> THIS FORM MUST BE ACCOMPANIED BY.ATIT(1)OR MORE PERMIT APPLICATION• FORM B UNLESS THIS I CHANGE OF <br /> FORM A(5-91) ^ r <br /> ATION ONLY. <br /> J FOPD033A-5 <br />