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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD +'e1� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE In <br /> MARK ONLY I NEW PERMIT E] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O T PERMANENTL <br /> ONE REM Q 2 INTERIM PERMIT Q # AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 5a <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> -Q Y/ V ISG , v N On O� wwAO� <br /> ADD SS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> l LQ fi a �Y s <br /> CITY NAME / STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> TjJv CA �O zoa —FFG — Zzo6 <br /> ✓BOX 0 CORPORATION 0 INDMDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY• 0 STATE-AGENCY' O FEDERAL-AGENCY* <br /> TO INDICATE DISTRICTS <br /> 10 o(UST6apubkaganly,mmbNMablbwmT w ofsupeniwof*bn ., ionwdFi ichW MOUST <br /> TYPE OF BUSINESS m I GAS STATION Q 2 DISTRIBUTOR Q ✓IF INDIAN RESERVATION #OF TANKS AT SITE E.P.A. 1.D.#(apda l) <br /> 0 3 FARM Q < PROCESSOR 0 5 OTHER OR TRUST lAN05 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> Y NAME(LAST,FIRST) HONE#WITH AREA CODE DAY E(LAST RS HONE#WITH R CODE <br /> TY <br /> hlim00D Zo S / 64417 4TC A)c9AA1 u —' 06,; <br /> NIGHTS: NAME(LAST,FIRST)I7 M O PHONE#WITH EA CODE NWS: NAME(LAST,FIRST) . P O�w� CO <br /> Ica <br /> VW <br /> 1,9_ <br /> II. PROPERTY OWNER INFORMATION--(MUST BE COMPLETED) (� <br /> NA #wlry /vl♦JO CARE OF ADDRESS INFORMATION <br /> MyLf ' R STREET A OFiEas I'T ✓ bas b bdrala DUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 5/I(ls (yam, 1T _Cf 0 CORPORATION 0 PARTNERSHIP CD COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME � STIyjE,- ZIP CO ^ �� IT�RAREA OODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> OyyN CARE OF ADDRESS INFORMATION <br /> MC/AI OR EET ADDRESS ✓ bmla aldml# NDMDUAL O LOCAL-AGENCY O STATE AGENCY <br /> �p I C 1141'l�E/L O CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY D FEDERAL-AGENCY <br /> SatZIP CQpE��O HONE#W TH DE D� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-F4--]- I- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓b#a b AftNe 0]-6ELFdNSURED 0 2 GUARANTEE 0 3 INSURANCE D I SURETY BOND Q 5 LETTEROFCRmn 0 6 EXEMPTION (]T STATE FUND <br /> O STATERIND&CHIEF FINANCIAL OFFICER LETTER O 9 STATE FUND 6 CERTIFICATE OF DEPOSIT 0 IO LOCAL GOVT.MECHANISM 0 93OTHER <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: 1. 11.O 111.0 <br /> THIS FORM HAS BEEN COM ETED UNDER PENALTY OF P RJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK (PRINTF I ) TANKOWNER'S TITLE DATE MON AYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE-OPTIONAL CENSUS TRACT# -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 /> OWNER MUST FILE THIS FORT#...' l THE LOCAL AGENCY IMPLEMENTING THE UNDERGROI'"STORAGE TANK REGULATIONS <br /> FORM A(15,95) 1-31- 00 x�j/, <br />