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esoun es <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w�� " -. <br /> 1� a <br /> �IfUN N`� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F—] 1 NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SIT <br /> ONE ITEM X2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA O FACILITY NA E NAME OF OPERATOR r' 8ahf-le <br /> AD E$ � D� / � NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> uxi- IF y <br /> CITY4/NLA/nM� �r��`- V, `./ STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> jl r CA I !q-a 4 <br /> ✓ BOX <br /> TO INDICATE O CORPORATION INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FI ST) PHONE#WITH AREA CODE DAY E(LAST.FIRST).��^ - (-j 'O) '1/h <br /> O <br /> NIGHTS: NAME(LAST,FAST) PHONE#4ITP AREA CODE NIGHTS: NAM ST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF DRESS INF MATION <br /> RC o ter to du d-s r� : � sem, <br /> MAILIN7 STREET ADDRE ✓ box to indicate = INDIVIDUAL = LOCAL-AGENCY Q STATE-AGENCY <br /> oRPORATION 0 PARTNERSHIP = COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME , STATE ZIP CODE PHONE# ITH AREA CODE <br /> ,8 0 ,c5 r .-• J- a o <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate = INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ4 4 - <br /> V. PETROLEUM UST FINANCIAL ESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED E�j 2 GUARANTEE [_1 3 INSURANCE 4 SURETY BOND <br /> I=5 LETTER OF CREDIT =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. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND ORRECT <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) APPLICANT'S TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY S <br /> COUNTY# JURISDICTION# FACILITY# <br /> al 1 1 11163 <br /> LOCATION CODE -OPTIONAL CENSUS CT# ;OPTogL SUPVISOR-DISTRICT CODE OPTIONAL <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) V _ Cl y�� FOR0033A-5 <br />