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rIyOVR r9 <br /> 00 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY El I NEW PERMIT O 3 RENEWAL PERMIT Z5�_,5 CHANGE OF INFORMATION 7 PERM ENTLY CLOSED SITE <br /> ONE ITEM [—] 2 INTERIM PERMIT 4 AMENDED PERMIT D 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA Cy FACILITY NAME NAME <br /> / r7'+ NAMES FOPERATOR <br /> "0m;5 //i /K-D"✓GGC Z4 C—. /t 007 *!f �7 `ld G. 12R JNk <br /> ADDRESS/3 <br /> U�#ro#, 1571- NEAREST OSS TR ETT��`,/ PARCEL p(OPT NAL) <br /> CITY NNAM`!/E STATE <br /> L((df' ZIP CODE SITE PHONE#WITH AREA CODE <br /> Sv406AL6 CA <br /> TOI/ Box <br /> INDICATE VrCORPORATION D INDIVIDUAL ED PARTNERSHIP L-1 LOCAL-AGENCY L-1 COUNTY-AGENCY STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR / <br /> IF IND <br /> IAN ON #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> O AT <br /> 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS 0 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME LLAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> /du.r< /%zZ2 a. �9 6F z3 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREACODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> CARE OF ADDRESS INFORMATION <br /> NAME/ OZ 'S A,-;4 dYfel Z`l C- <br /> MAILING OR STREET AD RESP , ./� ✓ W bindbate � INDIVIDUAL 11 LOCAL AGENCY STATE-AGENCY <br /> ACf 3 �/ �/ CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITUNAIE� <br /> /O !.}� STATE_CX <br /> ZIPCOSZ05 PH AREA <br /> �L5�2-3 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME,OFPWNERCAREOFADDRESS INFORMATION <br /> e &J <br /> MAILING OR STREET ADDRESS ✓ box 0 Wicate QINDIVIDUAL LOCAL-AGENCY I= STATE-AGENCY <br /> V,(CORPORATION PARTNERSHIP COUNTY-AGENCY I= 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 4 4 0 13 12 2-1 Z161 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bWicate Q I SELF-INSURED ID 2 GUARANTEE 3 INSURANCE 1 SUPETY BOND <br /> O 5 LETTEROFCREDIT =6 EXEMPTION O N OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: II II.❑ 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 /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 117 d a 2 6 ooM� y <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 3.80 3;Z <br /> 7 69� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS ISA CHANGE <br /> SITE INFORMATION ONLY. <br /> FORMA(5-91) <br /> FOR0033A5 <br />