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• • 'EsouA c o <br /> STATE OF CALIFORNIA :P <br /> STATE WATER RESOURCES CONTROL BOARD W dam, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT F7 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAM NAME OF OPERATOR <br /> sl <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> i zs ue�, <br /> CITY NAME STATE IF CODE SITE PHONE#WITH AREA CODE <br /> CA s-zyo <br /> ✓BOX 0 CORPORATION INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' (] STATE-AGENCYFEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> If owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS a t GAS STATION a 2 DISTRIBUTOR / a 6/IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> L_ �/ RESERVATION <br /> Q 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> D YS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> �G8" 663 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM a CARE OF ADDRESS INFORMATION <br /> 1 T q <br /> MAILING OR STREET ADDRESS bo indicate r0 INDIVIDUAL D LOCAL-AGENCY STATE-AGENCY <br /> ZS � i N!E ✓ CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STAT ZIP CODE PHONE#WITH AREA CODE <br /> O e'-z <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> lrckn2iAS <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL (] LOCAL-AGENCY 0 STATE-AGENCY <br /> /t(e- <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> C TY NAME STATE ZIP CODE PHONE It WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4_74- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED 0 2 GUARANTEE =3 INSURANCE 0 4 SURETY BOND 0 5 LETTEROFCREDIT =6 EXEMPTION =7 STATE FUND <br /> D 8 STATE RIND&CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND 8 CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM 0 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.d II.El III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SI T E) TANK OWNER'S TITLE DATE MONTHtDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 00375(p <br /> m 7 3 / I 30�R] <br /> LOCATION CODE -OPTIONAL ___]CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS IS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORW THE LOCAL AGENCY IMPLEMENTING THE UNDERGRtp STORAGE TANK REGULATIONS <br /> FORMA(6-95) % �� <br />