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�g0unce <br /> STATE OF CALIFORNIA APP cU� <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �e <br /> COMPLETE THIS FORM FOR EACH FACILrrY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANE CLOSED,SITE <br /> ONE ITEM D 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> 131 <br /> DBA O ILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> Lel-11,4A <br /> CITY,�AME STATE ZIP CODE SITE PHONE#WITN AREA CODE <br /> TO CA <br /> 9 , - <br /> ✓ BOX <br /> TO INDICATE VORPORATION 0 INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY­ E:�FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 77, GAS STATION 0 2 DISTRIBUTOR 0 RESERVATDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS ;31c2j\1 L 8300 6 336 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> D YS: NAME(LAST,FIRST) PHONE#WITH AREA CODEDAYS: NAME(LAST,FIRST) PHQNFjv WITH AREA MDF <br /> HTS: NAM ST,FIRST) . r xPHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) -d� – u—) – t t <br /> 2-0q - 36Q to 5�s«1•• e�e,,.su� <br /> PHONE#WITH AREA CODE_ <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS r ✓ box indicINDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> '� 2--s' W . rG �� ORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY AME STATE ZIP CODE PHONE#WITH AREA CODE <br /> ww�a� Cei �l 3 2 D225 -'23 3- 3'B L g <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER S CARE OF ADDRESS INFORMATION <br /> CT-'v�ti P` <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY 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—T-4]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF.INSURED 0 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT =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.[:] it.� 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 8 SIGNATURE) APPLICANT'S TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ON <br /> COUNTY# JURISDICTION# FACILITY# 3 7366 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> (0 It �� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFOFWATION ONLY. <br /> FORM A(5-91) FOR0033A-5 <br />