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• STATEOFCAUFORNIA • .4s „ <br /> STATE WATER RESOURCES CONTROL BOARD ^� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A <br /> ear a: <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT <br /> ONE REM ❑ 3 RENEWAL PERMIT El CHANGE OF INFORMATION <br /> ❑ 2 INTERIM PERMIT ED AMENDED PERMIT ❑ T PERMANENTLY CL,OSEp_SIT,E.. _ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) S TE APO ARV SITE CLOSURE <br /> DBq OR FAC��NgptE <br /> ADDRESS <br /> �l �,/� �� NAME OF OPERATOR <br /> ,'T. <br /> � -�� .. NF�REST CR0599TREET ) �� (� <br /> CITY NAME � i t /) � /�i n PAgCELN(OPrpNAU <br /> ✓ BO% CA / �-"� r. S TE PHONE i WITH AREA CODE <br /> TO INDICATE O CORPORgTON 7 <br /> D INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY <br /> If wmer of UST Is a public agency,conplate the following;name of Supervisor of dNlsbn, COUNTY-AGENCY' <br /> DISTRICTS' 0STATE-AGENCY- (] FEDERAL-AGENCY- <br /> TYPE OF BUSINESS eectbn,or office which operates the UST <br /> ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR <br /> ❑ 3 FARM ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.;I rapfionaQ <br /> ❑ 4 PROCESSOR 0 5 OTHER RESERVATION <br /> EMERGENCY CO OR TRUST LANDS <br /> NTACT PERSON (PRIMARY) <br /> DAYS: NAME(LAST,FwsT) EMERGENCY CONTACT PERSON (SECONDARY). <br /> PH NE;1 WITH AREA C�/ DAYS: NAME(LaGT,FIRST) I oAREA C <br /> NIGHTS: NAM (Lp$T,FIRST), V -x� S.�K�L PHONE 1`WITH AREA CODE <br /> 1 L T), P NE t1 WITH AREA CODE <br /> / �44` NIGHTS: NAME(LAST.FIRST)( PHONE 0 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME <br /> '! I •; � - CARE OF ADDRESS INFORMATION <br /> MAILINGORSTREET ADDRESS <br /> bw lo Nice <br /> CITU NAME } ' Y COgPORgTION INDIVIDUAL � LOCALAGENCV 0 STATE AGE NCV <br /> ' PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERALAGENCY <br /> -To <br /> ST9TE ZIP CODE <br /> A�� PHONE t WI H AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) S r <br /> NAME OF OWNER <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS � F� <br /> ✓ bmbindicate IIINDIVIDUAL <br /> 1'-'L LOCAL-AGENCY 0 STATE AGENCY <br /> CITU NAME O CORPORATION ( 1 PARTNERSHIP 0 COUNTY.AGENCYD FEDEMLAGENCY <br /> STATE ZIP CO)E PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE� FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bw bidiwte 0 I SELF-INSURED 0 2 GUARANTEE <br /> O&IETTEROFCREDIT 0 6 EXEMPnON 3 INSURANCE E�]4 SURETYBOND <br /> R99 OTHER I jZ i)r l— <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal noGGcation and billing will be sent to the lank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> I.❑ II. III.❑ <br /> -� R4MNas6EENCOMPLETED UNDER PENALTY OF PERJURY,AND TO THE SESTOFMY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) <br /> OWNER'S TITLE <br /> DATE MONTWDAYr1'EAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTYp <br /> JURISDICTION M FACILITY• <br /> J (� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT; . <br /> OPT/ONAL 9UPVISOR-DIET Tc�oE-gvTpµu <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A ISM) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR9W3AA7 <br />