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STATE OF CAUFORI" �' 1 <br /> STATE WATER RESOURCES CONTROL BOARD ; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETETHIS FORM FOR EACH FACILITY/SITE �.�„o„�•• <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT5 CHANGE OF INFORMATION 0 7 PERMIANENTL SITE <br /> ONE ITEM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT :K8 TEMPORARY SITE CLOSURE <br /> L FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR LITY NAME `' NAME OF OPERATOR Q <br /> seA <br /> ADDRESS ,"t NEAREST CROSSSTREETPARCELs(OPrpNJW <br /> CITY NAME STATE ZIP CODE SITE PHONE s WITH AREA CODE <br /> —r—P,i1CA - <br /> ./ BOX CORPORATION Q INDIVIDUAL Q PARTNERSHIP LOC&AMNCY <br /> TO INDICATE � Q DISTRICTS' QCOUNTY-AGENCY' QSTATE-AGENCY• <br /> 'N owner d UST Is a public agency.complete the f Q FEDERAL AGENCY' <br /> following:nacre d$uPwvisw d division,swion.or dlrKe whIch operates the UST <br /> TYPE OF BUSINESS L;jg: t GAS STATION O 2 DISTRIBUTOR Q ✓ IF INDIAN s OF TANKS AT SITE E P.A 1.0.s/gpLWkv <br /> Q 3 FARM Q 4 PROCESSOR = 5 OTHERORRESERVATION <br /> TRUST LANDS <br /> E MGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST.FIRS PHONE s WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE s WITH AREA CODE <br /> KCL 91(0- - 11 1LVA �tZ1Z`/ aO -414 <br /> NIGHTS: NAME(LAST.F ST) PHONE s WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> -4pt" - 7 Li -:35-72 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME i i CARE QF ADDRESS INFORMA N <br /> MAILING OR STREET ADDRESS ✓ box o Yuacue INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> T— ) Y11CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CRY NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER _ CAPE OADDRESS INFORMATIOgI � / <br /> MAILING OR STREETADDRESS _ ✓ bo:birdie I = INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> ) / J) 1 I / [CORPORATION Q PARTNERSHIP <br /> Q COUNTY-AGENCY Q FEDERAL AGENCY <br /> CRY NAME STATE ZIP CODE WITH AREA CODE <br /> t I PHONE s —AL_ <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. J , <br /> TY(TK) HQ 4 4- - 3 (a <br /> V. PETROLEUM UST FINANCIAL RESPONSIBIUTY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> b=ID I SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 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.= 11.= IIL�1 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> N NAME RINTEj I E ) T / IG� ���Lf <br /> OWN EIV VI ) DATE M TH/DAY/YEAR <br /> t1 l C �,L1 nuc { 1� <br /> LOCAL AGENCY US NLY <br /> COUNTY tf JURISDICTION FACILITY iI <br /> ® 3 �<4 <br /> LOCATION CODE -OPTIOAUTL CENSUS TRACT s-OPTIONAL SUPVISOR-DISTRICT CODE-GP770A4L <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESSTHIS IS A CHANGE OF SITE DFORMATION ONLY. <br /> FORM A(3/g3) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY WPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> • . FOR0033k417 <br />