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STATE OF CALIFORNIA • r� `Oa <br /> STATE WATER RESOURCES CONTROL BOARD a , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :�� sse <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMt <br /> SED,j SITE <br /> CNE ITEM 77. 2 INTERIM PERMIT 4 AMENDED PERMIT [�] e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> AGO 2a <br /> 6L <br /> lir► R, P1 t <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 2� 7r� 9 Lvb C-Lo./e- -f3 /6'a <br /> CITY NAMEr q,5--3-76 I STATE ZIP CODE ITE PHONE#WITH AREA CODE <br /> TO INDICATE 7 CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS1 GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.a(optimal) <br /> RESERVATION <br /> 3 FARM a 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE t WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> `v 0�1-X35=/6 e <br /> NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> Il. PROPERTY OWNER INFORMATION• MUST BEC D <br /> NAME,' CARE O ADDRESS INFORMATION <br /> M ILINGORSTREET ADDRESS ✓boxbWkale Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CI NAME STATE_ ZIP CODE PHONE x WITH AREA CODE <br /> _ r� <br /> III. TA OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER ff CC CA OF ADDRESS INFORMATION <br /> NAILING OR STREET ADDRESS ✓ i;x*indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> t fl ( Q PORATIOtI Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> ITY NAME STIyTE ZIP CODE PHONE#WITH AREA CODE <br /> . se g0_oZ 6 r �- �-z 7 6c5 <br /> IV. D OF EQUALIZATION UST STORAGE FEE ACC TNUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box*indicate Q I SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> Q 5 LETTER OF CREDIT Q B EXEMPTION Q 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 ch d. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. II <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> Z— -moi z <br /> LOCAL AGENCY USE ONLY496 <br /> COUNTY# JURISDICTION# FACILITY# <br /> aff] F7T_1 0 10 i a <br /> LOCATION CODE -OPTIONA CENSUS TRACT s -OPTIONAL SUPVISOR-DI TRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FOPM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0033A-5 <br /> L <br />