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�® VR <br /> STATEOFCALIFORNIA ` <br /> STATE WATER RESOURCES CONTROL BOARD <br /> 'n � <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATIO A_ <br /> r <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ) ;} <br /> I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMA I , 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY ❑ ❑ T ❑] ;, I <br /> ONE ITEM ❑� 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE ctosU♦� I <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA FACT TY NAM` � N E OF PERATOR <br /> i <br /> ADDRESS 9 NARESTCROSS STREET PARCEL 0(OPTIONAL)T <br /> CITY NAME STATE ZIP ODE SITE PHONE*WITH AREA CODE <br /> CA 5202) <br /> v BOX <br /> TOINDICATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY STATE-AGENCY Q FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION j77 2 DISTRIBUTOR 0 ✓ IF INDIAN #OF TANKS AT SITE I E.P.A. 1,D.#(optional) <br /> RESERVATION <br /> QI 3 FARM F 4 PROCESSOR 5 OTHER OR TRUST(ANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> D S: NAME(LAST,FIRST) PHONE#gWITH A EA C DE �DALY!S: AM ST,FIRST)f — S __rlvvvc <br /> NIGHTS: NAME(LAST,FIRST) PHONE ITH A A CODE NIGHTS: NAME(LAST,FIRST) <br /> 3jk 61A r <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 1 <br /> MAILING OR STREET ADDRESS J box bindicate Q INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAMESTA I ZIP CODE + PHONE a WITH AREA CODE <br /> Slum& AIll. TANK OWNER INFORMATION-(MUST BE COMPLETED) J <br /> NAME F ER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Dox b indicate Q INDIVIDUAL Q LOCAL-AGENCY ATE-AGENCY <br /> J+ Qja l-zm Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE®WITH AREA CODE <br /> 32L— 24LIO <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4_ 471-1013 12-1 <br /> V. <br /> 4 j- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate 15E3aSELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> =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: I.❑ II. III.❑ <br /> THIS FORM HAS BEEN COM6?LETEP UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> I '102A APPLICAN ' NAME(PRINTED ti SI APPLICANTS TITLE DATE MONTWDAY/VEAR <br /> LOCA GENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT e -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. <br /> FORM A(5-91) FOR0033A-5 <br />