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0 .0v <br /> STATE STATE OF CALIFORNIA APS - <br /> STATE WATER RESOURCES CONTROL BOARD Wim, <br /> �C UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �e <br /> 4 •' O <br /> •C�IIROR N�. <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY D 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION O 7 PERMANENTLY C <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT E 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> T SCS t <br /> ADDRESS NEARE TCROSS STREET PARCEL#(OPTIONAL) <br /> S1 i f Uro <br /> CITY NAME S ATE ZIP CODE SITE PHONE#WITH AREA CD <br /> v►-e C611 CA 95-5-56BOX <br /> TOINDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Q 1 GAS STATION 0 2 DISTRIBUTORQ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR � HER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME LAST, IRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> 1 6 - <br /> NIGHTS: NAWE(LAST,FIRS PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> O 1 tt9t ''_'Zflpv <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> E7014ri <br /> MAILING <br /> Q$ORRSTREET ADDRESS /� ✓ box bIndicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> 0 5 'v/ (_Q 1 ✓I �� „ S �T Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE 7P CODE Z <br /> NE#WITH AREA CODE <br /> c-tc-A/1 �'6c 5—2 a yom` - y6 7'-63 1 5 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> .- r►4 <br /> MAILING OR STREET ADDRESS ✓ box to Indicate <br /> Q INDIVIDUAL Q LOCAL-AGENCY QSTATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZtP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - o -L 15 1S Z ❑� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate Q 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 6 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.0 II. III.0 <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 MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# OOP? 17 <br /> 3 � 7 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> TUS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATIONONLY. <br /> FORWAL(5-91) FOR003 -5 <br />