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STATE OF CALIFORNIA i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA a <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> r_l PERMANENTLY CLOSED SITE <br /> MARK ONLY ❑ 1 NEW PERMIT <br /> ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Lel. <br /> ONE ITEM ❑ 2 INTERIM PERMIT <br /> A AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> E_] <br /> I. FACILrTYISITE INFORMATION&ADDRESS,-(MUST BE COMPLETED) <br /> OF OPERATOR <br /> ORA 09 FAC ILITE'� L� �• �- <br /> �—, l�� ` NEAREST CROSS STREET PARCFlt(OPfIONAU <br /> A o 50 A a4✓r'S ,2r.� <br /> STATE ZIP CQf 91 E t WITH AREA CODE <br /> CITVNAMEQ/ <br /> 4✓I�/BOX p CORPORATIDN O INDMWAL O PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' <br /> Q SFATEAGENCV' O FEDERAL-AGENCY' <br /> TOINpCATE DISTRICTS' <br /> •N owner d UST Is a PubSp Aeeh".PPP�P the fO 'RMP d BtpN'Mor d dNicbn.eectbn,or office wlibV IF ate,the UST <br /> INDIAN i OF TANKS AT SITE E.P.A. I.D.i(apfk-0 <br /> TYPEOFBU 1NNESS �I GASSTATION ❑ 2 DISTRIBUTOR RESERVATION t <br /> 3 FARM Q A PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> L (Piti Cpyp DANS: NAME(LAST,FIRST) PHONEi WITHAREA CODE <br /> / r ` PHONE i WITH AREA CODE <br /> [NIGHTS: NAME(LAST.FIRST) PHONE i WITH AREA CODE NIGHTS:NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME. � -/.i^ -7 ..; i�'�(\ <br /> " I- ✓bpi blydkYs El INDIVIDUAL O LOCAL-AGENCY STAAGENCYMAILS OB STREExDRESS / �Poyl*N 0 PARTNERSHIP 0 COUNTY-AGENCY FF(' OD <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAy1FiOf,BV/ /fJ-' •LeTL. <br /> f�I�t��!-' ✓bw bYtlkaU E=11 INOIVNNIAL O LOCAL-AGENCY C:]STATE-AGENCY <br /> M 25BTRE( QR� - <br /> (P y I�CORPOMTION = PARTNERSHIP 0W <br /> CNTY#GENCY FEDERIL#GE <br /> STA LP CODE PHONEi WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9 9 if queS6onS arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> 0 1 SELF-INSURED O 2 GUARANTEE INSURANCE Q A SURETY BOND <br /> ✓boW AS O 5 LETTER OF CREDIT O 6 EXEMPTION O 92 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: L❑ II.❑ 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 6 SIGNED) <br /> OWNER'STITLE DATE MONTFUDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUP,i JURISDICTION i FACILITY a <br /> pa"TON CODE -OPTIONAL TRACT P -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)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 REGULATIONS FORomMaT <br /> FORM A(3931 <br />