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STATE OF CAUFORMA J <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A > , <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT Lz,5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT0 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE `y <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAMEEOF ERATOR <br /> ADDRESS <br /> NEARk6 CROSS STREET PARCEL#(OPTIONAL) <br /> 7i 3 A990'J---- . <br /> CITY NA E � n STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> Cta CtJw' CA <br /> box <br /> TO INDICATE I1 CORPORATION O INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY [7)COUNTYAGENCY' STATE-AGENCY' 0 FEDERALAGENCY' <br /> DISTRICTS' <br /> If owner of UST Is a pubic agency,complete the following:name of Supervisor of oNlnbn,section,w oflice which operates the UST <br /> TYPE OF BUSINESS O S STATION Q 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.k I.D.•(cpbup <br /> O RESERVATION <br /> 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE i WITH AREA CODE <br /> NIGHTS: NAME(UST,FIRST) PHONE a WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE•WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> N� CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS -/ .1 bum Intimate p INDIVIDUAL E:3 LOCAL.WAGENCY 0 STATE-AGENCY <br /> I'1 S / v Q CORPORATION O PARTNERSHIP ED CNfY#GENCY I�FEDERAL-AGENCY <br /> CITY r STATE ZIP CODE PHONE A WITH AREA CODE <br /> NMI <br /> III. TANK OW4R INFORMATIO •(MUST BE COMPLETED) <br /> NAME OF OWNE ; CARE OF ADDRESS INFORMATION <br /> �.� Cl.yc..G— <br /> MAILING ORSTREET ADDRESS ✓bca b Irdems (] INDIVIDUAL [] LOCAL AGENCY ED STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP O CWKrY.AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE MPCODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if quesfions arise. <br /> TY(TK) HO 4 4- - I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ mor biMic to 0 I SELF-INSURED L:1 2 GUARANTEE E-1 3 INSURANCE 4 SUR ETYBOND <br /> =5 LETTEROFCREIXT =&EXEMPTION O 90 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is 9mcked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O It. III.Q <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&SIGNED) OWNER'S TITLE DATE MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If FACILITY IS <br /> 90NLY. <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPMML <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESSTHIS IS A CHANGE OF SITE IWORMAT <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3A13) FORIMMA7 N, <br />