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STATE OF CALIFORNIA w '•• °off <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EA FACILITY/SITE <br /> MARK ONLY I NEW PERMIT F7 S RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOs SITE <br /> ONE ITEM 2 INTERIM PERMIT 1= 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> , :) <br /> 1. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NA E NAME OF OPERATOR <br /> Qek- e� <br /> ADDRESS NEAREST CROSS STREET I PARCEL 0(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE 0 WITH AREA CODE <br /> CA � S -336 <br /> I/ Box <br /> TO INDICATE CORPORATION INDIVIDUAL Q PARTNERSHIP (Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESSI GAS STATION 2 DISTRIBUTOR = <br /> ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.0.#(optional) <br /> RESERVATION <br /> Q S 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) <br /> NIGHTS: NAME(LAST.FIRST) PHONE s WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> PWONP#WITW ARI:A <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME / i� CAAE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box aindicam Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME I STATE iZIP CODE� �� j PHONE WITH AREA CODE <br /> C <br /> dl 7/J� 7 if Z <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF AOORESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box m and cus —� <br /> Q INDIVOUAL a LOCAL-AGENCY Q STATE-AGENCY <br /> �Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> )V.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4747-!D I z-1 y 1,61&9 1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box a indiem Q I SELF-INSURED Q 2 GUARANTEE Q 7 INSURANCE Q 4 SURETY BOND <br /> C 5 LETTER OF CREDR 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= II.= III.= <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 MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGILITY#} <br /> I�vKI <br /> LOCATION CODE -OPT70NA'✓ j CENSUS TRACT s -OPTIONAL /_\ SUPVISOR-DISTRICT CODE -OP770NAL , <br /> THIS FORM MUST BE ACCOMPANIED SY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOROOO.IA5 <br /> r��+ CD �j <br />