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660Ua C <br /> STATE OF CAUFORNA <br /> STATE WATER RESOURCES CONTROL BOARD Y 4 6 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 0 1 NEW PERMIT 0 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION F___j 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME NAME OF OPERATOR <br /> 5;A o�9 vi <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE J SITE PHONE#WITH AREA CODE <br /> TO DI ATox <br /> E (]CORPORATION 0 INDIVIDUAL PARTNERSHIP (] LOCAL-AGENCY COUNTY.AGENCY• STATE-AGENCY' (] FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR 0 ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME `^ Jr CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b Indleate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> FiL��► (�CORPORATION (] PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATrA ZIP CO __TPHONE#WITH AREA CODE <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OWNER CARE OF ADDRESS INFORMATION <br /> �► cP�r G <br /> MAILING OR STREET ADDRESS ✓ box b indicate 0 INDIVIDUAL (] LOCAL-AGENCY 0 STATE-AGENCY <br /> D - Za =CORPORATION = PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE HONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 -I d 2-I q6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box ID indicate 1 SELF-INSURED Q 2 GUARANTEE Ej 3 INSURANCE Q 4 SURETY13OND <br /> D 5 LETTER OF CREDIT Q 6 EXEMPTION 0 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: 1.0 if.a III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTI N# FACILITY# #V% <br /> 3 Z <br /> 03 1116 Kq�sG <br /> io / <br /> LOCATION CODE -OPTIONAL CEN I�TRAS,T#-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> lei <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(3/93) • � FOR0033A-R7 <br />