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• e4ouw e. <br /> STATE OF CALIFORNIA cO� <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �: <br /> �(If01�N <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY D 1 NEW PERMIT 3 RENEWAL PERMIT rV 5 CHANGE OF INFORMATION F—] 7 PERMANENTLY CLOSED SITE <br /> 0 <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE l <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> tvDBA OR FACILITY NAM o C, NAME OF QP�6 0 r a) D <br /> ADDR�S$% NEAREST CROSS STREET P M(OPTIONAL) <br /> CITY(NNAA/—MEI 0 0, <br /> �g STATE Z COD SITE PHONE A WITH AREA CODE <br /> S CA <br /> I/ BOX CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY <br /> TO INDICATE � � � STATE-AGENCY � FEDERAL-AGENCY <br /> ��` <br /> /// DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION = 2 DISTRIBUTORRESER INDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.ii(optional) <br /> 0 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA COD DAYS: NAME(LAST,FIRST) <br /> -L1Lo sem 4�o 3�' SaPHONE A WITH AREA CODIP <br /> NIGHTS: NAME( T,FIRST) PHONE I WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> c <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAMEy CAR F ADDRESS INFORMA ION <br /> N r <br /> MAILING OR STREET ADDRESS ,y ✓ box toindicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> e © y CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY N STATE ZIP CODEP ONE a ITH AREA CODE <br /> III. TANK OWNER INFORMATION.-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> --- � 1l1 1Jz;110 <br /> MAILIN R STREET ADDR ✓ box to indicate INDIVIDUAL <br /> 0 LOCAL-AGENCY = STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NT E ZIP CODE PHONE#WITH AREA CODE <br /> ��4 <br /> IV.BOARD OF EdGALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO F4 4�- ___ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> C� 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: <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&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY v <br /> COUNTY# JURISDICTION# FACILITY# <br /> 9 LL I1 11713131 <br /> LOCATION CODE OPTIONAL !CENSUS TRACT# -OPTIONAL 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(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> A-R6 <br />