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cJunr?S <br /> STATE OFCALIFORNIA `9^ <br /> STATE WATER RESOURCES CONTROL BOARD <br /> re a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> y 1YT o <br /> COMPLETE THIS FORM FOR EACH FACILITWSITE <br /> MARK ONLY 1 NEW PERMIT 9 RENEWAL PERMIT CHANGE OF INFORMATION C 7 PERM SITE <br /> ONE ITEM 2 INTERIM PERMIT a AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLE T ED) <br /> DBA OR FACILIPf NAME �� NAME OF OPERATOR _ <br /> ADD ESS NEARESSS PARCEL <br /> a: x" <br /> CI NA STATE'• ZIP DE SITE PHONE x WITH AREA CODE <br /> _ t rKt� I <br /> CA 3 '.90102 S99. <br /> y_ <br /> TO INDICATE CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY _ COUNTY-AGENCY -STATE-AGENCY FEDERAL-AGENCY , <br /> DISTRICTS <br /> TYPE OF BUSINESS i GAS STATION r 2 DISTRIBUTOR _ ✓ IF iNC1AN x OF TANKS AT SITE E.P.A. I.0.x(optional) <br /> RESERVATION <br /> s FARM n a PROCESSOR I j 5 OTHER OR TRUST LANDS 1 JF S <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY .-tiAME(LAST,FIRS PHONE s WITH AREA CCOE DA • NAME(LAST,FIRST) CRO <br /> NIGi�T NAME LAST,FIRS— PHONE x WITH AgEA C.^.DE N HTS: NAME(LAST,;;I STj <br /> HONE s <br /> WITI-4 AREA CODE 01A.- <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME T1 14 � <br /> �^ I CARE OF AOORESS INFORMATION <br /> .MAILING OR ST AODR SS ) I ✓ box bindicm INDIVIDUAL LCCAL•AGENC .•�f STATE-A CY <br /> _ Q Sid L NciMA,. V ' ORPORATION PARTNERSHIP `COUNTY-AGENCY �i FEDERAL-AGENCY <br /> CITY NAME u.� .�STATE ZIP CODE PHONE;WITH AREA CODE <br /> — o 5-6i- 73V 6�i'a b <br /> III. TANK OWNER INFORMATION-(MUST 8E COMPLETED) <br /> NAME QE nw ER^ �� CARE OF ADDRESS:NFOR TION r <br /> 31 <br /> MAILING OR ET AO RESS ✓ box vindicate 77 INDIVIDUAL LCCAL•AGENCY STATE•AGENC <br /> 6 Q ! CORPORATION J PARTNERSHIP _CCUNTY-AGENCY -_ FEDERAL-AGENCY <br /> CITY N r STA ZIP C.^.OE 1' PHONE x WITH AREA CODE <br /> n 4- <br /> IV. BOAR F EQUALIZATION U&STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO �4 4 ;- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bo:to indicate 1 SELF-INSURED 2 GUARANTEE 9 INSURANCE J 4 SURETY BOND <br /> 5 LETTER OF CREDIT J 5 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 /> / <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L 11.7-7 111.y[ <br /> THIS FORM HAS BEEN OMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT /`" <br /> APPLICANTS NAME(PRINTED& El APPLICANTS TITLE DATE MONTHJOAY,YEAR <br /> I J t T4,cC K � )f $' <br /> LO AL AGENCY SE ONLY ,Z f5l <br /> COUNTY x JURISDICTION x FACILITY x <br /> 3_ t. <br /> -0 ATION CODE OPTIONAL CENSUS TRACT x -OPTIONAL SUPVISOR-DISTRICT CCOE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B, UNLESS THIS IS A CHANGE OF SI ON ONLY. <br /> =CAM A,12 911 FILE THIS FORM WITH.', ')CAL AGENCY IMPLEMENTING THE UNOERGRCUND ST- •ETANK REGULATIONS 1-3011 64-1 <br /> F R0033A•R6 <br />