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� . <br /> ILI <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD x vim, n o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A0 v( <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY -'lNEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT E::] 4 AMENDED PERMIT D a TEMPORARY SITE CLOSURE 01 <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) Q003Q/q <br /> DB jFAiLITVJAME N OFOPERATORIY <br /> ADDRESS�J 1..� N ( ` tL'�K�' <br /> �i BAREST CROSS TREET PARCEL/(OPrgNAU <br /> CITY NAME <br /> STATE IE, pE SITE HONE�WITH AREA CODE <br /> YSGJ0 _ocf-z <br /> ✓ BOX <br /> TOINDICATE CORPORATION Q INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY =1 COUNTYAGENCY' Q STATE-AGENCY' Q FEDERALAGENCY' <br /> If owner d UST le a ublic y ff DISTRICTS' <br /> p aeenc wnglda the[allowing: of Su rvisor of dNiabn,sectbn,or office Whbh OPaatee the UST <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DIST R IBUTOq ✓ IF INDIAN a OF SITE E.P.A, (aPlianal) <br /> 0 3 FARM O 4 PROCESSOR [70--5-OTHER O RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) -EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> �} ' ,IOC C GL, �f�'-Si'ry l ' '! <br /> NIGHTS: NAME(LAST PHONE 0 WITH AREA CODE NIGHTS:NAME(LAST, ST) PHONE a WITH AREA CO`E <br /> Gut eo i �Yu0 Za9 iSZ 5�l5E 5'),JT 0.0/ -SO 6 <br /> If. PROPERTY&NER INFORMATION• MUST BE COMPLETED <br /> NAMECARE OF ADDRESS INFORMATION <br /> PRINT <br /> MAII�NG�RST(gE�)ET A/D/DRErSS y_. ✓boa b I... l� INDIVIDUAL El LOCAL-AGENCY I] STATE-AGENCY <br /> ".•1177 OVOVAAVV • e O CORPORATION ) PARTNERSHIP Q COUNTY AGENCY 0 FEDERALAGENCY <br /> CI ME STATE ZIP CODE HONE A WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> N�FgWyEi 147fs CARE OF ADDRESS INFORMATION <br /> MA�¢.L71Li1KKTRl ET ADDRE3S ✓ bor kala INDIVIDUAL LOCAL AGENCY0 STATEAGENCY <br /> ....//L}V�l! `/_'Q�- LORPORATION O PARTNERSHIP 0 COUNTY AGENCY [:3 FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHON WITH AREA CODE <br /> cr� .S - ,; 4x!%o Zr� <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HO F4-[4--]- <br /> V. PETROLEUM LIST FINANCIA RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THEMETHOD(S) USED <br /> ✓ bm b intlkale t SELF INSURED =1 2 GUARANTEE O 3 INSURANCE <br /> O5 LETTEROFCREDIT O A SURETY a0N0 <br /> I�6 EXEMPTION Q 9B OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless tpx I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L II.0 M.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME WHIN TED&SIGNED)LQ? ` OWNER TITLE DATE MONTWDAYIYEAR <br /> 264 r°f�a'(_J C C <br /> LOCAL AGENCY USE ONLY <br /> COUNTY It JURISDICTION If - FACILITYX - � / / <br /> r. .41— <br /> LOCATIONCODE -OPTIONAL CENSUS TRACTi -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> R� <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. <br /> FORM A(3193) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK B&GULATIONS <br /> �/C/(/ FOIIOWUil7 <br />