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�50UR Q$ <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD w � °® <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 4 n <br /> o <br /> q ' <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 1 C�-A tf c I_ <br /> MARK ONLY F-1 t NEW PERMIT n 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANEN CLOSED SITE <br /> ONE ITEM 2 INTERIM._PERMIT__ E] 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE CO "LE1-EDy`-'~_1.1 <br /> DBA OR FACILITY NAM , C NAME OF OPERATOR <br /> S <br /> ADDRESS r �"A.IL je NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 1 Gtr 4J <br /> CITY(GAMEpv <br /> 6,114-4 �CODE STATESITE PHONE#WITH AREA CODE <br /> CA <br /> T01 ATE CORPORATION INDIVIDUAL Q PARTNERSHIP LOCAL-AGE BOX COUNTY-AGENCY STATE-AGENCY O FEDERAL-AGENCY <br /> `, DtSTRIC <br /> TYPE OF BUSINESS a t GAS STATION 2 DISTRIBUTOR _ ✓ IF INDIAN #OF TANKS AT SITE I E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 P R 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> t - �/ <br /> 0 14- <br /> NIGHTS: AME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS N ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP =COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> S V-T(i 2 ®e <br /> MAILING OR STREET ADDRESS• ✓ box to indicate = INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> t 0 ` ) CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME' STATE ZIP CODE 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 [4T41- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boz to indkate 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> 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 /> [CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[=] it.= III. <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/DAYNEAR <br /> r/ <br /> LOCAL AGENCY USE ONLY / <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE OPTIONAL I CENSUS TRACT# -OPTIONALSUPVISOR-DISTRICT CODE -OPTIONAL <br /> FA< <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 THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> (a 0 FOR0033A-R6 <br />