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C. <br /> 50�A �S <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> ERGROUND STORAGE TANK PERMIT APPLICATION- FORM, A <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [�j 7 PERMANENTLY CLOSEO <br /> ONE ITEM _ I 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME ( I NAME OF OPERATOR <br /> K�1z Ade, <br /> ADDRESS � NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 0 Utz/r" <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> S G✓ CA X20BOX <br /> 6 <br /> TOINDICATE Q CORPORATION EdINDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Q 1 GAS STATION Q 2 DISTRIBUTORQ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR 0 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#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY <br /> Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE I ZIP CODE PHONE#WITH AREA CODE <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicateINDIVIDUAL <br /> Q Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP 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 F4_57- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHO ) USED <br /> ✓ box to indicate 0 1 SELF-INSURED Q 2 GUARANTEE Q 3jP815RANCE Q 4 SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 6 EXEMPTION 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. IL III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> I <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> `� 117F] 10 10 �I t;l <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR- ISTRICT <br /> 2 CODE -OPTIONAL <br /> �, Yo Z <br /> j 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) 7 FOR0033A-5 <br />