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l • ft'f VII . C <br /> STATE OF CALIFORNIA • �� <br /> a STATE WATER RESOURCES CONTROL BOARD + ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM A �� n <br /> COMPLETE THIS FORM FOR EACHFACILITY/SITE <br /> MARK ONLY O I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT E:14 AMENDED PERMIT a TEMPORARY SITE CLOSURE ' <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) C <br /> DBAOR ILITY AME NAMEOFOPERATOR <br /> 6 Q-1 k0,44 III':C- <br /> ADDRESS <br /> :C-ADDRE S NEAREST CROSS STREET PARCEL N(OPTIONAL) <br /> Ra I- <br /> CITY NAM STATE ZIP DE SITE PHONE#WITH AREA CODE <br /> �� CA <br /> TO INDICATE CORPoRATION IJy INDIVN1UAl 0 PARTNERSHIP O LOCAL-AGENCY O COUNTY AGENCY' (]STATE-AGENCY' O FEDERAL-AGENCY' <br /> If miter d UST lea public en � B; DISTRICTS- <br /> p agency.wnplete the following:name of Su visor of ONkbn,sectbn,w office which operates the UST <br /> TYPE OF BUSINESS iO t GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN N OF TANKS AT SITE E.P.A. I.D.#foplionag <br /> 3 FARM 4 PROCESSOR 5 OTHER O RESERVATION <br /> O O OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAV A NAME(LAST.FIRST) ` PHONE#WITH AR �C,ODE DAVE: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> Re 4!+ Ca J Y <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAMEn CARE OF ADDRESS INFORMATION <br /> 91/ M I�"t <br /> MAr OR STREE DRESS - ^ -µ ✓ bo+blMbate INDIVIDUAL LOCAL-AGENCY ED STATE-AGENCY <br /> 1 O CORPORATION PARTNERSHIP 0 CWMY-AGENCY 0 FEDERAL-AGENCY <br /> CI E TATE ZIP COD P NaEaW AREACODE <br /> � - <br /> III. TANK OWNER INFORM N-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bintlbate INDIVIDUAL 0 LOCAL-AGENCY 0 STATE AGENCY <br /> O CORPORATION O PARTNERSHIP I=COUNTY AGENCY 0 FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ 4 <br /> —F4--]-��u <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box Wildcats, 1 SELF-INSURED 2 GUARANTEE Q 3 NSURANCE <br /> O O I SURETY BOND <br /> 5 LETTEROFCREDIT <br /> 0 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[:] II. IN. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> n <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OP NAL SUPVISOR-DISTRICTCODE -OPTIONAL <br /> �3 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3/a3) ` 7— ^� FOR0033A-R' <br /> W-k-V"-tL,�1 S/a-e c71 c9„-� <br />