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0 ` <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> •C�I�Fo�N`� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ��J,,,�///`1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM <br /> E] 2 INTERIM PERMIT Lj 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA(2�ACILITY NAME NAME OF OPERATOR <br /> ADDRE S 1 -70 <br /> �� � ' _- � y NEAREST CROSS STREET PARCEL p(OPfIONAL) <br /> ---IIIIIIyIII,�"��J N <br /> CITY NAME � `_� TATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> I/ BOX CORPORATION 0 INDIVIDUAL (� PARTNERSHIP (� LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY <br /> TO INDICATE (] 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: (LAST,FIRST) PHON #WIT AREA CODE DAYS: NAME(LAST,FIRST) <br /> 7 " "'5a46q1 PHONE S WITH AREA GODF <br /> - <br /> NIGHTS: NAM (LAST,F ST) HONE><WI AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> NAME � %%'l�� CARE OF ADDRESS INFORMATION <br /> MAILI Gt�REETADDR SS 6 ✓ box to indicate IN VIDUAL LOCAL-AGENCY <br /> O FEDERAL-AGENCY(,/ 0 CORPORATION � PARTNERSHIP 0 COUNTY-AGENCY � FEDERAL-AGENCY <br /> CITY NAME STATE ZIP C DE PHONE N WITIA AREA CODE <br /> C i- 9!P0 ,62-V5 13 <br /> III. TANK OWNER IdFnRMATinN-(MUST BE COMPLETED) <br /> NAME OF OWNER _ CARE OF ADDRESS INFORMATION <br /> S r r <br /> MAILING OR STREET ADDRESS ✓ box to indicate = I UAL LOCAL-AGENCY <br /> (] STATE-AGENCY <br /> CORPORATION = PARTNERSHIP E:] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE 'URNEA ITHEA CODE <br /> f aga -G <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ [4 4 l-L] <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate = t SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 7 5 LETTER OF CREDIT 6 EXEMPTION CJ 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BiLL.ING 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.F-1 II.E:1 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> 4, u:7yCANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHlDAYNEAR <br /> LOCAL AGENCY USE ONLY 7 <br /> COUNTY# JURISDICTION# FACILITY# <br /> IT_ <br /> � 3 <br /> LOCATION CODE OPTIONAL CENSUS TRACT# OPTIONAL SUPVISOR-DISTRICT DE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION. FORM B,UNLESS THIS IS A CHANIbE OF SITE INFORMATION ONLY. <br /> FFORM A(12-91) FILE THIS <br /> /FORM WITH <br /> THE <br /> �LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE GULATIONS <br /> R0033A R6 <br />