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x s 1 ,tet. <br /> 7777 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM,A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE c'�ironN`' <br /> I - <br /> MARK ONLY F—] t NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 FOMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I.* FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ` <br /> • C o ,FACI�N E NAME ."C0 OP_EII�?t�• <br /> ADDRESONEAREST CROSS STREET PARCEL (OPTIONAL) <br /> !q© pt s\ �I.1 tr 0CI # :4 <br /> CITY NAME STATE ZIP CODE SITE PHONE r WITH A CODE <br /> 5.15 Z Gt3lox50 <br /> ✓ BOX <br /> TO INDICATE =`66RPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL•AGENCYDISTRICTS' 0 COUNTY-AGENCYSTATE-AGENCY' FEDERAL-AGENCY' <br /> iel If owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> r TYPE OF BUSINESS 0 f GAS STATION 0 2 DISTRIBUTOR0 ✓ IF INDIAN #OF TANKS AT SITE E.P.A. , j-ok*.*phonal} <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS a <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Itck <br /> PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRS DE <br /> 4419 <br /> NIGHTS: NAME(LAST,FIRST) T) PHONE#WITH AREA CO <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> rATE CARE OF ADDRESS INFORMATION <br /> AILING OR STREET ADDRESS t ✓ box b Indicate 0 INDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY <br /> a?-CORPORATION (] PARTNERSHIP [=1 COUNTY-AGENCY = FEDERAL-AGENCY x` <br /> (CITY NAME STATE ZIP CODE PHONE <br /> P+H+ONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWN{fq4 // CARE OF ADDRESS INFORMATION <br /> c^e.+n Gc�. `�St"t°�: � tf;� �-�-s~�r•E� v-+, `-_.~�l'..:.t h H <br /> MAILING OR STREET ADDRESS ✓ box Ile indicate0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CX -�` �d cvnrtFRATION O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> ITYNAME STATE ZIP C E PHONE#WITH AREA CODE <br /> !. <br /> (a $ <br /> IV.BOARD OFtQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-96691if questions arise. ' <br /> • TY(TK) HQ 4- - 0101 -717 3 R x¢ <br /> 4 <br /> _ w <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boxbindicate (] t SELF-INSURED 2 GUARANTEE 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 /> 41. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> t THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> i ' <br /> OWNER'S NAME(PRINTED R SIGNED) OWNER'S TITLE DATE MONTWDAYlYEAR <br /> i LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <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 THIS IS A CHANGE OF SITE INFORMATION ONLY. t <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3/93) FOR0033A-R7 <br /> �k�F,•: 2 int � X <br />