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110 <br /> bOun <br /> STATE OF CALIFORNIA a ni <br /> STATE WATER RESOURCES CONTROL BOARD ��, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> y �rt,rUyi <br /> COMPLETE THIS FORM FOR EAC ILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> CNE ITEM '❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> s6u ti es �oines <br /> ADDRESS NEAREST CROSS STREET PARCEL a(OPTgNAU <br /> 3 M r /e <br /> CITY NAME STATE ZIP CODE SITE PHONE x WITH AREA CODE <br /> J BOX CA 9� TiaiLe- 9 3=02,1 <br /> TO INDICATE C21COAPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY 0 COUNTY AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 RIBUTOR O ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.A(optimal) <br /> RESERVATION <br /> ❑ 3 FARM 4 PROCESSOR I❑ 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> CP 2 u n Gt/ <br /> NIGHTS: — PHONE a WITH <br /> AME(LAST,FIRS PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> ll. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Surma asl <br /> MAILING OR STREET ADDRESSp ✓ lroa minEkata Q INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> Q /�J X 310 O CORPORATION PARTNERSHP 0 COUNTY-AGENCY 0 FEDERALAGENCY <br /> CITY NAME STATE Z;CODEo/ PHONE#WITH AREA CODE <br /> sjo c%{-aa-g C11 9S7_ <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Iqa pumiata l0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> _ 0 CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERALAGENCY <br /> CITY NAME - STATE ZIP CODE PHONE II WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER r Call(916)323.9555 if questions arise. <br /> TY(TK) HQ 4 4 - 9 a a4 3 Z <br /> V. PETROLEUM LIST FINANCIA ESPONSIBILITY•(MUST BECOMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ Ow birAkaN 1 SEURNSUREO l0 2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND <br /> D 5 LETTEROFCREDIT O 6 EXEMPTION 0 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.❑ 11.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPUCANT'S NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> C�OUN�TY# JURISDICTION# FACILITY# <br /> tial ET—T-1 / 6 Q P 11T5 3 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT CODE - <br /> OPTIONAL <br /> 0 so 3a.3 <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) *r,r /� FOR0033A-5 <br /> • V 1 <br />