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STATE OF CALIFORNIA "p <br /> STATE WATER RESOURCES CONTROL BOARD 3 mom, ,y S <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 3 <br /> COMPLETETHIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY D I NEW PERMIT O 3 RENEWAL PERMIT X5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE <br /> ONE ITEM 0 2 INTERIM PERMIT F1 4 AMENDED PERMIT [:] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DB OR AGILITY NAM NAMEOFOPERATOR <br /> IV at <br /> ADD 1767 ^� NEA ST CROSQ.6.TFjEET PARCEL'ToprgNAL) <br /> CITY NAME STATE ZIP CODE- S� P 12 W,%q— <br /> CA <br /> TOI/ BOX <br /> INgC TE CORPORATION 0 INDIVIDUAL (]PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY O STATE-AGENCY (] FEDEMLAGENCY <br /> DISTRITS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR / <br /> IF INDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.x(optimal) <br /> 0 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DA : NAME LAST,FIRST) NE>f w'1�AR� DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE I WITH AREA CIODF <br /> II. PROPERTY <br /> ('{IOWNER INFORMATION- MUST BE COMPLETED <br /> NAM // V V CARE OF ADDRESS INFORMATION <br /> MAILIfjI(a OR 3T%E(T DRES ✓ box biotlbab l� INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> o'I/1/.C/�5 =CORPORATION (] PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITYJtY�4E, � STATE ZI CCOD�D� ONE WITH AREi CODE <br /> Q lJ� <br /> III./, TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME gF53}NNE / IVCARE OF ADDRESS INFORMATION <br /> 1Y;1 <br /> AIINGOR STR TADD BB ✓WxbindkaN 0INDIVIDUAL OLOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL#GENCY <br /> C NAME STAT ZIP CODE PHONE ITH EACODE <br /> vvu q - m 7a <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BEC MPLETED)—IDENTIFY THE METHOD(S) USED <br /> ,1bnxbinEbab O I SELF-INSURED 2 GUAR E 0 3 INSURANCE 1--1 4 SURETYBDNO <br /> D S LETrEROFCREDT L-3 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: L[:1 II-5X' 1111-1 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLEDATE MONTWDAYNEAR <br /> L,+aR y G 3�2�Au�e v P, -i �.,o!e _ /-!� - 10 <br /> LOCAL AGENCY USE ONLY C5 `Re c, I �3 1q0Y <br /> COUNTY# JURISDICTION# FACILITY#DO&I7'I <br /> LOCATION CODE -OPTIONAL CENSUS TRAC-# -OPTIONAL SUPVISORO-DIST�CT DE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY.AATCI,LEAST(11))OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(691) RECD CTIENG. FORI=A5 <br /> N.. ..o WAN 10 19% <br />