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• e SOUR e <br /> STATE OFCAUFORNIA Ar" .-' �O <br /> STATE WATER RESOURCES CONTROL BOARD s <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 1��� '�0 <br /> •C��If Oft N.f <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 0 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION EV7 PERMANENTLY CLOSED SITE <br /> ONE ITEM E:1 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> � � Sx le-.4 C✓q � <br /> ADDRESS nn NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> o�So f �ti C LS m <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> (fSCzi CA 9s320 <br /> ✓ BOX <br /> TO INDICATE (]CORPORATION INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS a 1 GAS STATION 0 2 DISTRIBUTOR / IF INDIAN IN OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> MERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> aA f-t e.X 3G-7/ <br /> NIGHTS: NAME(LAST, RST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 11,11t / PHONF#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> �..f M G �ec,)3 <br /> MAILING OR STREET ADDRESS ✓ box bindicate INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> e✓► �-orvlct t y'S(f)C_ 31=x$ <br /> 1, TANK OWNER INFORMATION-(MUST BE COMPLETED) 408 33 6 - P!&-t/S <br /> E OF OWNER r v� CARE OFADDRES$INFORMATION <br /> w/O it S� <br /> MAILING OR STREET ADDRESS �7 ✓box to indicate E�:] INDIVIDUAL = LOCAL-AGENCY STATE-AGENCY <br /> U 3 5?S Q CORPORATION 0 PARTNERSHIP E::] COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Vbou �v^- 77Z1a 96/6 &2 368.6253 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise.-713 6 <br /> TY(TK) HQ 4 4 - O jo -3g S❑ ex 513 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindicate 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 0 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.[:] it.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT y <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOICT 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 dflLY. <br /> FORM A(5-91) FOR0033A-5 <br /> rC'C . 3� 10 <br />