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STATE OF CALIFORNIA ���� `q <br /> STATE WATER RESOURCES CONTROL BOARD :d®� o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORF CIUTY NVE NAME OF Z& <br /> L+ <br /> 46 <br /> ADDRESS <br /> A/. NEARE CROSS ST E6� / PARCEL#(OP nONAL) <br /> bmvtDo <br /> CITY NAME STATE ZIP CODE SITE PHON N WIT^ARF@ CQD� <br /> TO INDICATE Box <br /> xxTE ED CCCOO•RPPORAI,TIIONwv, NOIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' (] FEDERAL-AGENCY. <br /> DISTRICTS <br /> No rof USTbapubucagency,cmi*o Nufokw T.clan WsaPermorofdivabn,section or WAW which operates the UST <br /> TYPEOFBUSINESS [�j GASSTATION Q 2 DISTRIBUTORO RESE✓IRFINDIAN ROFTANKSATSITE P.0. I.D.#(op#onal/ <br /> IV TION <br /> 0 3 FARM Q # PROCESSOR Q 5 OTHER OR TRUST LANDS pal( 73(pop <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(UST,FIRST) PHONE WITH AREA CODE DAYS: NAME(LAST.REST) PHONE N WITH AREA CODE <br /> L/ G /-/69I <br /> NIGHTS: NAME(USST,_REST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> $ag <br /> MAILING OR STRJiGI�tiff .1 haxto iedCb MLOCAL-AGENCY STA <br /> TiAGENEO CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME ZIP CODE TH EA CODE <br /> '7,520 21 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OyIALER CARE OF ADDRE FORMATION <br /> MAILING OR STREET AD ESS - ✓ box to exdale <br /> !�MOIVIOUAL (]LOCAL AGENCY (] STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP D COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> 0? -aSd l <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 -F]-T-FTT� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box M locale I SELF-INSURED =2 GUARANTEE O 7 INSURANCE =#SURErYB%D a 5 LErrEROFCREDIT Q e EXEMPTION O T STATE FUND <br /> = 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9STATE FUND BCERTIFICATE OFDEPOSIT OigLOCAL GOVT.MECHANISM O99OTHFA <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: I.❑ 11.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK WAME(PRINTED& IG TANKOWNER'S TITLE DATXnE MONn*DAYA'EAR <br /> C/ Z� <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION# FACILITY X <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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(695) <br /> OWNER MUST FILE THIS F�H THE LOCAL AGENCY IMPLEMENTING THE UNDERC, ,TORAGE TANK REGULATIONS <br /> ��./ <br />