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OUR [ <br /> STATE OF CALIFORNIA p �� <br /> �tP w <br /> 9 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY D 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION PERMANENTLY CL fT <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA_QR-FACILITY NAME — <br /> NAME OF QP RATOR <br /> n kllb <br /> ADDRESS / NEAR ROS TREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITEPH N #WITH AREA CODE <br /> CA /� <br /> BOX <br /> TO INDICATE ORPORA N Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTORQ ✓ IF INDIAN #OF TANKS ATS E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> NAME( AST,FIRST) PHO 4WTH AREA CQpE_& DAYS: NAME(LAST,FIRST) <br /> pau-c-d 4? PHONE a WITH AREA rf)r)F <br /> NI : NAME(LAST,FIRST) PHONE#WITH AREA CCCO.//E NIGHTS: NAME(LAST,FIRST) <br /> v -2PHONE#WITH AR A CODE <br /> z�f�l <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CAR DRESS INFORku1AT10N <br /> Cx '= <br /> MAILING OR STREET ADDREP ✓ ae INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> a P-eCRPmnON Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> C AME e4TATE ZIP CODE PHONE,,WITH ARE CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OW CARE OF ADDRESS INFORMATION <br /> MAILING O TREETA DR S ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> -69RPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> C NAME S E ZIP CODE P9QNE#WITH AREA OD <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4T_41- 8 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box ID indicate Q 1 SELF-INSURED Q 2 GUARANTEE SURANCE 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.Q 11- <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> ICANTS NAME(PRIN E &SIGNATURE) APPLICANTS TITLE DATE MONTH/D NEAR <br /> b� RA 13/2- <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 51 <br /> LOCATION CODE -QETIQNAL CENSUS TRACT# - TI A SUPVISOR-DISTRICT DE -OPTIONAL <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 /> FORM A(5-91) FOR0033A-5 <br />