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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A o <br /> 3 <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> ❑ 8 <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT o •,/•o- ,',o <br /> ONE ITEM ❑ 5 CHANGE OF INFORMATION rpy.�,�., <br /> ❑ 2 INTERIM PERMIT ❑ # AMENDED PERMIT O T P�r ��••1•Y CLOSED SITE <br /> B <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) TEMPORARY SITE CLOSURE 9 In\c Jy <br /> DBA OR FACILITY NAME ( , <br /> r NAME OF OPERATOR <br /> ADDRESSftJAS <br /> NEAREST CROSS STREET PARCEL#(OPTIONAL <br /> CITY NAME AtI <br /> STATE ZIP CODE SITE PHONE tl WITH AgEA CODE <br /> ✓BOX C� CA <br /> CORPORATION INDIVIDUAL 0 LOCAL-AGENCY <br /> TO INDICATE O PARTNERSHIP COUNTY-AGENCY• (_J STATE-AGENCY, <br /> •BoamdUSTbaPd�9cagwKy.wmpbN lM klbw' nanHds DISTRICTS FEDERAL-AGENCY' <br /> 4NMswd Grvban,sMbnwdBce which#perelnlM UST <br /> TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR ✓IF INDIAN X OF TANKS AT SITE E.P.A <br /> 1.D.X roplionel) <br /> 3 FARM ❑ 4 PROCESSOR E::] 5 OTHER OOp ESERVRUSTATION <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CO/DE DAYS: NAME(LAST,FIRST) <br /> A Z� - e,• tine j 1� PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE X MTIJ AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE tl WITH AREA C DE <br /> LEAN VkaN c <br /> If. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFD) <br /> NAME CARE OF ADDRESS INFORMATION <br /> P. S7y9.ry <br /> MAILING OR STREET ADDRESS P:DIYIWAL LOCM-AGENCY (] STATE-AGENCY <br /> QjP 1 L AIA O CORPORATION Q PARTNERSHIP COUNTY-AGENCY 11 FEDERAL-AGENCY <br /> CITY N E STATE ZIP CODE PHONE#WITH AREA CODE <br /> i- C4 S s f" Z-L 25 120 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER ^^ CARE OF ADDRESS INFORMATION <br /> /J <br /> MAILING OR STREET AD/OR GS ✓ O#aN ivJipi# MWAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> r&, L =CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CIN NAME STATE ZIP CODS PHONE X WITH AREA CODE <br /> J7S3G <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-[4--]- <br /> V. <br /> 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓Ws pinr&gX O 1 SELF-INSURED O 2 GUARANTEE 0 3 MRANCE l=#SURETYSOND O 5 LETIEROFCREDIT 0 8 EXEMPTION T STATE FUND <br /> O8 STATE FUND BCHIEF RNANOALOFFICER LETTER 09 STATE FUND ACERTIFICATE OFDEPOSIT = 10 LOCAL GOVT.MECHANISM = 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNERS NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHYDAYNEAR <br /> ZF '7'7S 4 - <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION a FACILITY a <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> � J <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION btiLy. <br /> OWNER MUST FILE THIS R VITH THE LOCAL AGENCY IMPLEMENTING THE UNDERG VD STORAGE TANK REGULATIONS <br /> FORM A(5-95) 1. >,= <br />