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OJM t <br /> STATE OF CALIFORNIA J o^ <br /> STATE WATER RESOURCES CONTROL BOARD 3 m'`e <br /> � <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e � ''a <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION PVr7 PERMANENTLY CLOSED SITE <br /> ONE ITEM (] 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> 7 I41 ano AA.u� G J!. •� <br /> ADDRESS � NEAREST CROSS STREET PMCELA(OPTONAU <br /> oS'a 'DI ft . o►d <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> T Box (]CORPORATION 0 INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY <br /> 6 gICTS�CY COUNTY-AGENCY STATE-AGENCY O FEDEIU4AGENCY <br /> TYPE OF BUSINESS O I GAS STATION 2 DISTRIBUTOR / IF INDIAN=—/ RESERVATION a OF TANKS AT SITE E.P.A. I.D.#(Mbanal) <br /> 0 3 FARM 4 PROCESSOR [ 5 OTHER OR TRUST LANDS S <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> /,'45I w <br /> 1y41ce LO q-L/107-&0'. <br /> NIGHTS: NAME(LAST,FIRST) PHONEA WITH AREA CODE NIGHTS: NAME LLASL FIRST) <br /> PHQNF 9 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> T u w K-j <br /> MAILING OR STREETADDRESS ✓ blbbdwab E-1 INDIVIDUAL LOCAL-AGENCY []STATE-AGENCY <br /> x CORPORATION O PARTNERSHIP D COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> T - v ach C+ 952c�f <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> S 4 A ,_ as C 7t <br /> MAILING OR STREET ADDRESS - `�- ✓ boa blMicau INDIVIDUAL (] LOCAL-AGENCY L7 STATE-AGENCY <br /> Q CORPORATION O PARTNERSHIP D COUNTY-AGENCY FEDERAL#GENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ [4]-4]- 3 2 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Mx IolMiale 0 1 SELF-INSURED 2 GUARANrEE 3 INSURANCE []4 SURETY BONG <br /> 5 LETTEROFCREDIT 6 EXEMPTION LJ 66 OTHER <br /> 71 <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is c ed. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II. III-F-1 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL ICENSUS TRACTa -OPTIONAL SUPVISOR DISTRICT CODE -OPTIONAL <br /> 0 Ya 1 (y3 <br /> THIS FORM MU T BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS s� <br /> 6// FOfl00]]AR6 <br /> 1 �� <br />