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• • Yeaoun e <br /> STATE OF CALIFORNIA _° "� <br /> STATE WATER RESOURCES CONTROL BOARD w s <br /> / UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ": <br /> ,�OI,Y�n <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 17 <br /> O I NEW PERMIT 3 RENEWAL PERMIT . 5 CHANGE OF INFORMATION [—] 7 PERMA SED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY E NAME OF OP RATOR <br /> 1 r /c et5 - G?9 r/ <br /> ADDRESS /o NEARE TCROSS STREET PABCELp(OWIONALI <br /> V e / 45�✓) <br /> CITY NAME STATE ZIP C E SITE PHONE#WITH AREA CODE <br /> a c Ca <br /> ✓ BOX CORPORATION Q INDIVIDUAL D PARTNERSHIP I�LOCAL-AGENCY I�COUNTRAGENCY O STATE-AGENCY D FEDERAL AGENCY <br /> TO INDICATEDISTRICTS <br /> TYPE OF BUSINESSI GAS STATION O 2 DISTRIBUTOR = RESERVATION IF INDIAN <br /> N #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME( ST,FIRST) PHONE x WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> PHONE WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 86b- 32t-iW6 <br /> Il. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME `�, CARE OF ADDRESS INFORMATION <br /> n <br /> MAILING OR REET ADD//pp//ESS 4 ✓ box WIndkate = INDIVIDUAL = LOCAL-AGENCY =1 STATE-AGENCY <br /> `O )•A O U t 6 O'CORPORATION l� PARTNERSHIP 0 COUNTY'-AGENCY L� FEDERAL <br /> CITY NAME 1JJ STAT ZIP C E P ONE#WITH AREA CODE <br /> if e-d � � y510 0 7 5-669/ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF O`�NER \\ � /� CARE OF DDRESS INFORMATIO <br /> �L)S ).Oinel (0 QnA N 1, Sv✓1 <br /> MAILING OR SPET ADDRESS ✓ box 0Inmale E-1INDIVIDUAL0 LOCAL-AGENCY =1 STATE-AGENCY <br /> I// PORATION L� PARTNERSHIP = COUNTY-AGENCY � FEDEML-AGENCY <br /> CITY NAME STAT ? ZIP CODE HONE#WITH AREA COD <br /> ti �O n 61p/ <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questiorls arise. <br /> TY(TK) HQ F4_41- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boxiomdicale 0 I SELF-INSURED E�:]2 GUARANTEE 3 INSURANCE E::] 4 SURETY BOND <br /> O 5 LETTEROFCREDT L—)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 It is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.D 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 NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> C�# JURISDICTION# FACILITY ('(/$7(r7 tel' <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL ' yA <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 /> FORM A(5.91) FOR0033A 5 <br />