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5ouace. <br /> 0 S <br /> STATE OF CALIFORNIA ^P r <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A � �� <br /> .�. ; o <br /> •C�(IIDR N,� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT J 5 CHANGE OF INFORMATION F_� 7 PERMANENTLY CLOSED SI <br /> ONE ITEM n 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR A�TY NA�( - �/ - NAME OF OPERATOR <br /> ADDRES G •(]" f-J- NEAR ST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME 4 C — — S ZIP ODE ` /� 5ITE PHONE#WITH AREA CODE <br /> rJ 2f✓ � 1 V d 7— <br /> Box 9 7 <br /> TO INDICATE CORPORATION 0 INDIVIDUAL PARTNERSHIP [_] LOCAL-AGENCY 0 COUNTY-AGENCY E-1 STATE-AGENCY I7 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR / IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> - EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(L ST,�IRST) PHItE#WITH AREA CODE NAME(LAST,FIRST) -tl D �•�� l/ R <br /> N NAME(LA Tl FIRST)—✓ ` PHONE#WAREA CODE NAME(LAST,FIRSM <br /> (016 PHONE WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL (] LOCAL-AGENCY <br /> STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMED O NER ' CARE OF ADDRE S INFORMATION <br /> --- KC Q P r t) duct 3 : C. J_1 � <br /> MAIL! G OR STR ET ADDR S ✓ box to indicate <br /> 0 INDIVIDUAL OLOCAL-AGENCY (� STATE-AGENCY <br /> - 3 CORPORATION 0 PARTNERSHIP � COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY AM ,, Tg E_ ZIP CODE �—�� PHONE tW�AREA CODE �� <br /> * 7 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4[4 1-L L-...1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> ].� 5 LETTER OF CREDIT 6 EXEMPTION C1 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 /> F <br /> HECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. <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/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTTYY/# JURISDICTION# FACILITY It <br /> 3L_'? <br /> LOCATION CODE OPTIONAL i CENSUS TRACT# OPTIONAL SUPVISOR-DISTRICT CODE -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(12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATII S <br /> n.r (`a3 [� LJ OR0033 -R6 <br /> OV <br />