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• � PbbOJA [ PU <br /> P <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3�` <br /> w � y° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A !�„ a <br /> �41sUXN�P <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT LJ CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAME OF OPERATOR <br /> DBA OR FACILITY NAME <br /> NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> ADDRESS <br /> CITY N E STATE <br /> ZIP CODE _ SITE PHONE#WITH AREA CODE <br /> eox <br /> TOIN BOX O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP O LOCAL-DISTRIAGENCY � COUNTY-AGENCY D STATE AGENCY 0 FEDERAL-AGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR '/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> ❑ RESERVATION <br /> FARM 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,y IRST) PHONE#WITH AREA CODE i DAYS: NAME(LAST,FIRST) <br /> OWl Eil - a!'�7-33 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> 5,xQt7 4-;'�4 ✓ box btrdka a NDIVIDUAL 0 LOCAbAGENCV 0 STATEAGENCY <br /> MAILING OR STREET ADDRESS <br /> 3rJ =CORPORATION = PARTNERSHIP COUMYAGENCV FEDERAL-AGENCY <br /> C TMvl x'70 l , STATE, ZIP CODE P'ONEx WITH AREA CODE <br /> NAMEIII. TANK OWNER INFORMATION-(MUST BE COMPLETED) C//AL fir x J <br /> / CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> �� Lv ✓ boxbindicate NDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> MAILING OR STREET ADDRESS <br /> P O- Q� =CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITU NAME / STATE ZIP CODE PHONE#WITCO*AREA CODE <br /> G - file 45Z2 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 -Pjyj 6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bax blibkale 1 SELF INSURED �2 GUARANTEE O 3 INSURANCE L d SURETY BOND <br /> 5 LETTEROFCREDIT O 6 EXEMPTION D 96 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: 1.=] N. III.O <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 B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# # <br /> � C� n <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISORDISTRICT CODE -OPTIONA��3 <br /> gs <br /> THIS RM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION['- F`'/ORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.FOR0033A 5 \ <br /> FORM A(5.91) <br /> c7N,� G <br /> r <br />