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I <br /> Vw t C <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ee , a <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE TE) DWI <br /> 1 NEW PERMIT O 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION L /T C, <br /> MARK ONLY CII <br /> ONE ITEM 2 INTERIM PERMIT F 4 AMENDED PERMIT a 9 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) AUG 24 1992 <br /> OBAORFACI TY NAME NAME OPERA R a <br /> t <br /> ADOR S NEAR T CROSS ST Er "J"CES ES <br /> CITY NAME TATE ZIP 55 `'�� / SITE PHONE A WITH AREA CODE <br /> ✓ x 'CORPORATION INDIVIDUAL PARTNERSHP Q LOCAL.AGENCY COUNTY.AGENCY STATEAGENCY FEDERAL#GENCY <br /> TOINDIGITE <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR RESERVATION <br /> I/ FINDIAN Is OF TANKS AT SITE E.P.A. L D.A roplronal) <br /> Q 3 FARM Q 4 PROCE390R r 5 OTHER OR TRUST LANDS �. <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•opllonel <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> I e -SF7 n9 2P AM HARPA <br /> IN NAME(LAST,FIR PHONE A WRH AREA CODE NIGHTS: 14AME(LAST,FIRST) <br /> TOLc <br /> II. PROPERTY 0 ER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> u — ZE�7- <br /> MAILING OR STREET#WRESS INDIVIDUAL Q LOCAL-AGENCY Q STATFAGENCY <br /> PORATION D PARTNERSHIP O COUNTY-AGENCY O FEDERAL#GENCY <br /> CITY NAME TATE ZIP CODE PHONE 0 WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER tt�TDDRESS INFORMATION <br /> t <br /> Bro y!MAILI OR STR T R SS �,} �/ icate O INDIVIDUAL O LOCAL AGENCY I�STATE-AGENCY <br /> (� �- /DZ) RAPON O PNRNERSHIP O COUNrYAGENCY O FEDERAL-AGENCY <br /> CITY NAM ZIPCODE PHONE a WITH AREA CODE <br /> - 3 6 _ �a -oil <br /> IV.BOAR O4F EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)32& if questions arise. <br /> TY Tic +Q 4 - O .3 0-23iD <br /> V. `PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED —M/o— <br /> ✓ <br /> box bk&Ate Ij t SEURNSURED ED 2 GUARANTEE L—I ]INSURANCE 01 SURETY BOND <br /> O 5 LETTER OF CREW S EXEMPRON 0 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I�orr 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOP LEGAL NOTIFICATIONS AND BILLING: 1.0 Il.y I III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAIVE(PR INTED A SI�ANATI�WE) APPLICANTS TITLE DATE MONTWDAVNEAR <br /> / 7/ v <br /> LOCAL AGENCY USE ONLY <br /> COUNTV�A Z v JURISDICTION <br /> JZ., F �IL RFY# <br /> J <br /> LOCATIONCODE�OP TION CENSUS TRACT -OPTIONAL - OR-DISTRICT CODE -OPTq <br /> L.. <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(5.91) � /� FORW31A5�7 <br /> //1 <br />