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STATE OF CAUFORWA a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EA FACILITYISITE <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM a 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> D F <br /> TY NAME L _ !/O q1 n NAM F OPERATOR <br /> AT S yin _`/V'/-L!'/G 1Jw ESTCR STREET P/giCELt(OW (gN/AU <br /> CITU All!✓'fN J/ STATE ZIP ' SI PHONEt NTH A±Z DD <br /> CA ZD — <br /> T Nv BoxDICATE O OORPORATKNI INDIVIOUAL 0 PARTNERSHIP O OWTRI AGENCY COUMY-AGENCY' O STATE-AOFHCY' O fEDEML#OENCY' <br /> N owner d UST is a public agency.mnplete the following:name d SupervYor of eNbbn,sedbn,w duce which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR RESERVATIF ll�DION aOF TANKS AT SITE E.P.A. I.D.a(aPNmeq <br /> Q 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST) PHONE t WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> Il. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING REET ADO Be ✓sm b Mica 0 INDIVIDUAL D LOCAL AGENCY O STATE-AGENCY <br /> awk <br /> 0 CORPORATION 0 PARTNERSHIP O ODUNTYAGENCY FEDERALAGENCY <br /> CITY N BTI�E ZIPDE� PHONE t WITH AR (XOOE �/� <br /> l//�L11 ( J <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ mxbhbbais INDIVIDUAL (] LOCAL-AGENCY 0 STATE AGENCY <br /> 0 CORPORATION PARTNERSWP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 14K- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓bo[blMkaM D I SELF-INSUSED O 2 GUARANTEE O 3 INSURANCE D 4 SURETY BOND <br /> O 5 LETTEROFCREDIT O 6 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: LE:1 11. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED&S IGNED) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> CO3UNTY 9x � yy] JURISDICTIONx � FACILIIV• O � ��I�/ <br /> Flp 98 N/ <br /> LOCATNONCODE -/OP710NAL CENSUSTRACTx - SUPVISOR-DISTR �, <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS tS IS ACHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(393) <br /> FORMMA7 <br />