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�gOuw <br />9 <br />STATE OF CALIFORNIA p cG <br />STATE WATER RESOURCES CONTROL BOARD W, <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a ➢ <br />COMPLETE THIS FORM FOR EACH FACILrrYISITE <br />MARK ONLY O 1 NEW PERMIT a 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br />ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT F-] 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA_0R FACILITY NAME <br />NAME OF PERATOR <br />DAYS: NAME (LAST, FIRST) <br />PHnNF: # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />AD RESS <br />NE EST CROSS, STREEJ <br />PARCEL 0(OPTINAL) <br />CORPORATION Q PARTNERSHIP <br />Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CIT�IAME <br />CITYN ME <br />STATE <br />ZIP CODE_ <br />176 2, <br />,SITE PHONE #-WITH AREA CODE <br />/i <br />CA <br />l6 <br />- W/ <br />TOINDIICATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL -AGENCY Q COUNTY -AGENCY Q STATE -AGENCY Q FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS1 GAS STATION Q 2 DISTRIBUTOR <br />0 R SER INDIAN <br /># OF TANK AT SITE <br />E. P. A. I. D. # (optional) <br />Q 3 FARM Q 4 PROCESSOR Q 5 OTHER <br />OR TRUST LANDS <br />i <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />PHnNF: # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />il_ PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />/'0n <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />MAILING OR STREET ADDRESS <br />✓ bo Indicate Q INDIVIDUAL <br />Q LOCAL -AGENCY Q STATE -AGENCY <br />* <br />CORPORATION Q PARTNERSHIP <br />Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CIT�IAME <br />STATE ZIP CODE _ <br />HONE WITH AREA CODE <br />M - <br />®1 <br />l6 <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box toindicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY <br />Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />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 4 4 - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE CO PLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box oo indicate Q 1 SELF-INSURED 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br />O 5 LETTER OF CREDIT Q 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: 147 II. f7 III. F7 <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/OAY/YEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # <br />JURISDICTION # <br />FACILITY # <br />51 <br />ellcvx 66 <br />= <br />LOCATION CODE - OPTIONAL <br />ICENSUS TRACTP - OPTIONAL <br />I SUPVISQR _DISTRICT CODE - OPTIONAL „m , ®, 11 <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - <br />FORM A (5.91) <br />2 <br />B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />FOR0033A-5 <br />Ll <br />D <br />