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w <br /> STATE OF CALIFORNIA i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a^Y a <br /> COMPLETE THIS FORM FOR EACH FACILIrYISITE <br /> 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> MARK ONLYd AMENDED PERMIT S TEMPORARY SITE CLOSURE <br /> ONE REM 0 2 INTEflIM PERMIT O Q <br /> I. FACILfTYISITE INFORMATION III ADDRESS-(MUST BE COMPLETEED)NAME OFOPERATofl <br /> DBBAAORRFACILIT11Y��NAME ` \/ 1 <br /> J \O K On- l.. T< NEAREST CROSS STREET PARCELA(OPTUAU <br /> ADDRESS � -,O0� <br /> �a a %"* STATE Z�IPyCODE <br /> 9TTE PHONE#WITH AREA CODE <br /> CITY NAME (�`A — .I- Z,O q"'1 t— �• <br /> Lrd' <br /> ✓BOX LOCAL-AGENCY 0 COUNTY-AGENCY' O SGTE-AGENCY' O FfDERAL-AGENCY' <br /> TOIN BOX t�CORPORATION INDIVIDUAL 0 PARTNERSHIP DIRTFUCTS' <br /> •n owner d UST Is a publb agency oortp 1,the following:r d SuWv"r d dl iebn,aectbn,or dlia which pparalel 1116 11 <br /> UST <br /> ✓ IF INDIAN #OF TAN KS AT SITE E.P.A. I.D.#(apArWl <br /> TYPE OF BUSINESS O i GAS STATION Q 2 DISTRIBUTOR RESERVATION <br /> 0 3 FARM O d PROCESSOR ry 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•Gpttoful <br /> DAYS:NAME(LAST.FIRST) PHONE#WITH AREA CODE 7VsNAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NKiHTS: NAME(LAST.FIRST) S: NAME(LAST' <br /> FIRST) PHONES WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- MU7771 <br /> ADDRESS INFORMATION <br /> NAME Z <br /> $,I( CJlOr\ Oh inditm = INDIVIDUAL =LOCAL-AGENCY �STATE AGENCY <br /> MAILING OR STREET ADDRESS <br /> PORATION O PARTNERSHIP O COUNTY+AGENCY FEDERAMAGE <br /> kZ.B W ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME c}533Cp <br /> �o- <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER ^T A <br /> MAILING OR STREET ADDRESS 0 INDIVIDUALtPH <br /> LOCAL AGENCY STATE-AGENCY <br /> p <br /> CORPORATION O PARTNERSHIP -AGENCY O FEDERAL-AGENCY <br /> STATE ZIP CODE s WITH AREA CODE <br /> CITY NAME <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ 4 4 - D 2 5 (o <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> I SELF INSURED D 2 GUARANTEE BURANCE (]1 SURETY BOND <br /> ,/ lar niMkaie 5 LETTER OF CREGT 8 EXEMPTION <br /> �9D OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless Ox 1 or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1. 11.0 III.❑ <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(PRINTED A SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY i <br /> X31 s ja <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL BUPVL90R-DISTRICT CODE •LIPTIOMOU. <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK R ULATWNS /POROGI3ART <br /> FORMA("3) <br />