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STATE OF CALIFORNIA '' <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> FF COMPLETE THIS FORM FOR <br /> EACH FACILITYISITE °r�.a�+`' <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 5 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACILITY NAME NAME OF OPERAT, O`– O V� <br /> ADDRESS ^ NEAR ST CROSSSCTJRIrE�EYT PARCEL 0(OPFONAU <br /> l/—V� 1 I c <br /> CITY NAM (� r / STATE ZIPYCiODE O SITE PHONES WITH AREA CODE <br /> A)hAe— <br /> I/ Box <br /> TO INDICATE CORPORATION INDIVIDUAL 0 PARTNERSHP l� LOCAL.AGENCY � COUNTY AGENCY' 0 STATE.AGENCY' O FEDERAL-AGENCY' <br /> J ' owner d UST b a public agency. DISTPICTS <br /> If <br /> p B ^cY•conplala the lopowine:name d Supervhor of tlivlabn,eectbn,Soflioa which al>eralea the UST <br /> TYPE OF BUSINESS 0 i GAS STATION Q 2 DISTRIBUTOR RESERVATION <br /> IF INDIAN <br /> a OF TANKS AT SITE E.P.A. 1.0.s(aptimmae <br /> 0 3 FARM 0 4 PROCESSOR X5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS:NAME(LAST,FFAR VftIRST) PHONE Af Ahs WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA oGNIGHTS: NAME(LAST,FIR HONE a H AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> N A <br /> A CARE OF ADDRESS INFORMATION <br /> M 1 O TREETADDRESS ✓boxbindmae INDIVIDUAL ED LOCAL-AGENCY O STATE-AGENCY <br /> A 0. O CORPORATION O PARTNERSHIP 0 couNrY-AGENCY FEDERAL-AGENCY <br /> CI NAM 9TA ZIP PHONE a—WITH AREA CODE <br /> �c�0 ao4 a- <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boa bk&ab INDIVIDUAL 0 LOCAL-AGENCY I�STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP O COUNrY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE S WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(9 16)322.9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ Goa bindkme 0 1 SELF-INSURED O 2 GUARANTEE0 3 INSURANCE 0 4 SURETY SONO <br /> 0 5 LETfEROFCREOIT =9 EXEMPTION 0 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.[�] 1.[1] III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> CAINE R'S NAME(PR INTED B S IGNED) OWNER'S TITLE DATE MONTWDAYNEAFI <br /> LOCAL AGENCY USE ONLYge�rD 501,50-3 <br /> COUNTY a JURISDICTION R FACILITY 0 <br /> LOCATION -OPTIONAL CENSUSTR O-OP O SUPVISOR-277 -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,U ESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UND fl STORAGE TANK REGULATIONS <br /> FORM A(393) 4 FOINW]AAi <br />