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STATE OF CALIFORNIA <br />D <br />STATE WATER RESOURCES CONTROL BOARD o° <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A .s o <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT % 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br />CNE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ELI <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FA �IL �TY NAME <br />$ 5715 <br />NAME OF OPERATOR <br />13ob PkC-00*"6 <br />iV�uro�°� <br />" -AR vo� . <br />NEAREST CROSS STREET <br />PARCEL # (OPTIONAL) <br />ADDRESS <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />Q COUNTY -AGENCY FEDERAL -AGENCY <br />CA <br />STATE <br />ZIP CODE <br />Li4SB'3 <br />✓ BOX <br />TOINDICATE E::] CORPORATION &$D INDIVIDUAL E::] PARTNERSHIP LOCAL -AGENCY 0 COUNTY -AGENCY STATE -AGENCY FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS (4 1 GAS STATION = 2 DISTRIBUTORR <br />SERVATION / IF INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />0 3 FARM 0 4 PROCESSOR = 5 OTHER <br />OR TRUST LANDS <br />Li <br />Ld0 �g (o <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) a2 p 17 - 3 b 6 — 9 61 If <br />Ta_y%Pta_ . 2017- ?60- $64 c,Cow•-b gowPHONEP01— <br />NIGHTS: NAME (LA 6 , FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) p 1 — 3bp— 4667 /G 6 7 <br />Lt,✓�e�L o� - 333 - b��� Nle.Ca to P, T C! <br />PHUF'LH I Y UWNEK INI-UKMA I IUN - (IVIUJ I tit UUIViF'Lt I tU <br />NAME V /� GAHE OF AUUHESS INFUHMA I IUN <br />sV QX V-1 !t <br />MAILING OR STREET ADDRESS ✓ box Io Indicate INDIVIDUAL LOCAL -AGENCY STATE -AGENCY <br />00 - �� ARL S� . CORPORATION PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME STATE ZIP CODEPHONE # WITH AREA CODE <br />I -z 4-'^ <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />C f� L <br />CARE OF ADDRESS INFORMATION <br />DATE MONTHiDAYtYEAR <br />" -AR vo� . <br />W15. AS4.l <br />�l - f 7 _.. j7 Z_ <br />MAILING OR STREET ADDRESS <br />✓ box to indicate Q INDIVIDUAL <br />LOCAL -AGENCY STATE -AGENCY <br />IT? ©- td0 S004 <br />CORPORATION PARTNERSHIP <br />Q COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME,� <br />S..'� <br />STATE <br />ZIP CODE <br />Li4SB'3 <br />PHONE # WITH AREA CODE <br />S10- 94-a -17 sod <br />l�W%om- <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />TY (TK) HQ 4 4- D 3 11 `j t 3 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED <br />✓ box to indicate 1 SELF-INSURED L] 2 GUARANTEE (] 3 INSURANCE C 4 SURETY BOND <br />5 LETTER OF CREDIT 0 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: L� <br />THIS FORM HAS BEEN COMPLETED fNDT PENL�I7ERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANT'S NAME (PRINTED & S NATURE) <br />APPLICANTS TITLE <br />DATE MONTHiDAYtYEAR <br />r <br />vtD fz. �o1{n)� <br />� <br />W15. AS4.l <br />�l - f 7 _.. j7 Z_ <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # FACILITY # <br />LgGA10N CODE -OPTIONAL CEI) S TR T # -OPTIONAL SUPVISSOR-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 />