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g Y by`I 00,'3 'esoo. a <br /> STATE OF CALIFORNIA y �^ <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> C�tIiO�M�� <br /> COMPLETETHIS FORM FOR EAC CILrTYISITE <br /> MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT 4. AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION 6 ADDRESS-(MUST BE COMPLETED) <br /> NAME QF OPERATO\ <br /> DBA OR FAC�LI��� � �o. � l!S_IFp-TC�Z`�+V <br /> ADDRESS(s H`w+ NEAREST CROSS STREET PARCEL N(OPIDNAU <br /> 290 A. CPd_LF-eI"I A ST u <br /> CITV AM STATE ZIP CODE SITE PHONE 0 WITH AREA OODE <br /> CII <br /> cA q 7202 <br /> ✓ BOX ' COflPoflATION j INDIVIDUAL O PARTNERSHIP E]LOCAL-AGENCY Q COUNTY-AGENCY STATE-AGENCY D FEDERAL-AGENCY <br /> TOINgCATE DISTRICTS <br /> TYPE OF BUSINESS O L GAS STATION E�j 2 DISTRIBUTOR RESEIF RVATION AN A OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> 0 3 FARM 4 PROCESSOR � 5 OTHER OR TRUST LANDS ' 1fhIJ 8,3q?"?� <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA rnnp <br /> PHONE#WITH AREA CODE71 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ��Cl-A'2 9�dTD IN.'U77 U�. I fJL <br /> MAILING RSTREET ADrDRESS/� ✓J y�nd�H = INDIVIDUAL = LOCAL�AGENCY Q STATE AGENCY <br /> G�(.�Wim. ;V COPPORATION = PARTNERSHIP =COUNTY-AGENCY E-1 FEDERAL AGENCY <br /> CITY NAy� STATE ZIP OE PHONE a WITH AREA CODE <br /> (d/\ D 2. <br /> III. TANK OWNERINFORMATION-(MUST BE COMPLETED) <br /> NAME 010?R A_e CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ EoabiMkale INDIVIDUAL O LOCAL-AGENCY I]STATE AGENCY <br /> O CORPORATION D PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE i WITH AREA CODE <br /> IV. BOARD OFUAdZATION UST STORAGE F4 ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4 <br /> f , <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bm Wi dcm C 1 SELF INSURED D 2 GUARANTEE 0 3 INSURANCE 4 SURETY FxIND <br /> IJ 5 LETTER OF CREDIT 0 6 EXEMPTION =W OTHER <br /> 771 <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L O Il.iB' III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PETHII MY KNOWLEDGE,IS TRUE AND CORRECT <br /> A LICANTS NAME(PRINTF A SIGNATURE) 1�.FPLJ TI DATE MONTH/DAYNFAH <br /> �ar`ts I <br /> LOCAL AGENCY USE ONLY 15 uv ft%vip q—C� <br /> COUNTY# JURISDICTION# FACILITY x <br /> LOCATION CGDE -OPT/ NAL !CENSUS TRACT_A -OPTIONAL SUPVISOR DISTRICT CODE -OPTION <br /> 12- <br /> THIS FORM MUST BE ACCOMPANIED BY AT LJLEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A IIs en FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> Fgi0033AR6 <br />