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STATE OFCAUFORNq `w <br /> STATE wATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE - <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 NEWAL PERMIT n <br /> ONE ITEM ❑ 5 CHANGE OF INFORMATION E:17 PERMANENTLY CLOSED SITE <br /> ❑ 2 INTERIM PERMIT f?/, AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME FOPERATOR <br /> a T�,L�x RESTj <br /> ADDRESS <br /> 3535 5 . CheroKe.e- R "11,40 n PARCELI(OPRONAL) <br /> CITY NAME STATE ZIP CODE SITE PH E#WITH AREA CODE <br /> cA 95205 <br /> r BOX CORPORATION Q INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY O COUNTY-AGENCY' STATE. y* FEDERAL-AGENCY" <br /> TO INDICATE DISTRICTS <br /> M oanerol USTis a pibk agm,tlrpisafM foaming:name dSUPKA ral&ISIM Wien waft Midi operates the UST <br /> TYPE OF BUSINESS1 GAS STATION ❑ 2 DISTRIBUTOR O ✓IF INDIAN #OF TANKS AT SITE E.P.A 1.D.#(apfbnaq <br /> RESERVLANAD10 l O <br /> ❑ 3 FARM O # PROCESSOR Q 5 OTHER Oq TRUST DS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•grUOnar <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAY : NAME(LAST FIRST) PHONE WITH AREA CODE <br /> e cc Ell-5 (510) of n2e 2A51 44 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME QRST,FIRST) PHON WITH AREA CODE <br /> r ✓ (510 754-200 r ✓ zbq) `1-0995L <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME - CARE OF ADDRESS INFORMATION <br /> C cc. - C hlhl ro no <br /> MAILING OR STREETADD ESB ✓ baxtoh e Q NOMDUAL O LOCAL-AGENCY (] STATE AGENCY <br /> /d)o O CORPORATION Ctt>DE'PAROIERSHIP O CPOUONNTYE-A#GWENITCHY AREA COFDEED <br /> ERAL-AGECY <br /> CITYMSTATELP <br /> 061 C * <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> C"echmi Cec InJ v Arloyarvylivni <br /> MAILING OR STREET ADDRESS ✓ Mxlondinde NDMDUAL Q LOCAL-AGENCY O STATE AGENCY <br /> E h-60*fth S+. %4 18 =CORPORATION [XARTNFASHIP l=COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STALE— ZIP COD PHONE#WITH AREA CODE <br /> +1-04h �/' x�9 SID 757 �700 <br /> IV.BOARD OF EQUALIZAAT�IOO�N, LIST STORAGE <br /> S'TOORRAAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓paYb#14tN O I SE1.F4MRED O 2 au~rm l3 3 INSURANCE O#SURETYBOND O 5 LETTEROFCREDrr =&ExENPT10N Q T STATEFUND <br /> O a STATE RIND&CHIEF FINANCIAL OFFICER LETTER Oa STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM = 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: 1.❑ 11.❑ ILL❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTYOF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> ERS INAMq(PRINTED&SIGN RE) TANK OWNERSnTLE DATE MONTHrDAYNEAR <br /> AYC <br /> AL A#kNCY USE LY r <br /> COUNTY If JURISDICTION# FACILITY# b <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. o e`er <br /> OWNER MUST FILE THIS FORD"'rTH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROI"'I STORAGE TANK REGULATIONS <br /> FORM A(6.0) `' `� <br />