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„. <br /> - �SpURCES <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD Y � o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> a <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMAN LY CL SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE _. <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILIJY NAME �..... NAME OF OPERATOR ate- <br /> ADD ESS FN J -V • IYp � '; �t "� L( C_ •• <br /> r., NEARESTCRpSS EET PARCEL#(OPTIONAL) <br /> OX.p <br /> AbdL <br /> CI NA ++ STATE ZIP cF SITE PHONE#WITH AREA CODE <br /> -- CA <br /> I/ X <br /> �3 fir' j <br /> TO INDICATE CORPORATION INDIVIDUAL 0 PARTNERSHIP E71 LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTORI/ IF INDIAN 1#OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> O 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYSr�E(LAST,FIRST PHONE#WITH AREA CODE DA NAME(LAST,FIRST) 1. w� O <br /> _ �: ,,.,5 _ utiCker 0W, �,� <br /> A CODE <br /> NIG• vAME(LAST,FIRST) PHONE#WITH AREACODE' TS: NAME(LAST,FI ST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME r..: ., CARE OF ADDRESS INFORMATION <br /> l '.-.� wt V 5 d opt +*cDr� �d U+ <br /> MAILING OR STADDR SS ! ✓boxIoindicate INDIVIDUAL '. 0 LOCAL-AGENC 0 STATE-A NCY <br /> d c: 4 ( d"... ORPORATION' 0 PARTNERSHIP COUNTY-AGENCY I� FEDERAL-AGENCY <br /> CITY NAME i / STATE ZIP CODE PHONE#WITH AREA CODE fJ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> ' NAME QZZW ER CARE OF'AODRESS INFORrTION < Mt- <br /> - 5-0 uJ to 3 4-- <br /> MAILINGORT ETAD RESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE•AGENC <br /> i <br /> (}_ �► ” CORPORATION PARTNERSHIP COUi1 QE(, FEDERAL-AGENCY <br /> CITY NAU"rr • STA ZIP CODE � PHONE#WITH AREA CODE <br /> i IV. BOARD-61F EQUALIZATION US STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br />' V TY(TK) 00„ 144 - 1A 1-115171 <br /> �� PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> I ✓ box M indicate_ 1SELF-INSURED �2 GUARANTEE [� 3 INSURANCE 0 4 SUflETY BOND <br /> r 5 LETTEROFCREDIT �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 /> CHECK ONE BOX INDICATING WHICH ABQVi ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN OMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED& E) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> i <br /> LO AL AGENCY PAE ONLY <br /> COUNTY# JURISDICTION# , FACILITY# <br /> LOCATION CODE -OPTIONAL !CENSUS TRACT# -OPTIONAL I 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(12-91) FILE THIS FORM WITH THF LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> • FOR0033A-R6 <br /> L - - <br />