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a <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT Q 3 RENEWAL PERMIT 6 CHANCE OF INFOR TION 0 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT [_1A AMENDED PERMIT ED] S TEMPORARY SITE CLOSURE 0 <br /> I. FACILITYISLTE, INFORMATION ADDRESS (MU$fi9EE01AI ETEB1 <br /> TLj <br /> ORFLI _TYNAME NAME <br /> zle, c - A70A <br /> ADDRESS <br /> 11 NEA $TTC)ROSS4 `y"TpS7�7/y PMCEy's(OPrgNAL) <br /> Li yIaQJY (A-Q. 1rF WPI' <br /> C ME <br /> STSITE PHONE S W AREA CODE <br /> B.COpE�ATE D <br /> ✓BOX <br /> CA ( -sIS147-t9�3v <br /> TOINDICATE RPORATION I1 INDIVIDUALI1 PARTNERSHIP LOCAL-AGEWY O COUNTV-AGENCY• O STATE-AGENCY' <br /> 'N owner d UST M a public agency,conplas NIe lolowl DISTRICTS' ID FL'DEMLAGENCY <br /> rp:name d SupeN4w d dNbbn,Mlcibn,or offloe which operalae the UST <br /> TYPE OF BUSINESS O 1 OAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN A iiTANKS pT SITE E.P.A. I.D.e T(pNmWJ <br /> 0 3 FARM Q A PROCESSOR �5 OTHER OR TRUST ATIONLANDS 1 OV-ceb �e <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optimal <br /> DAYS: YAM L/�ST �FI P ONE a KITH Afl�F(JDDE DAYS: NAME(LAST. R T) PON a W AgEp COpE <br /> N S:N E(LAS FIRS PHONE a WITH Eq/Ul`3 S: NAME( ,f T) P IXJE WIT Aqv/✓L L/O <br /> 11 �i 2-t�i f �- � <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bublMktle L_j INDIVIDUAL L.]LOCAL-AGENCY ED STATE-AGENCY <br /> 1B Z O CORPORATION O PARTNERSHIP p COUNTY#ANCY f� FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE I PHONE a wRTH AREA CODE <br /> Sa V,\ _cl,mo yN n A4458 2 �S- 018 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> ^ CARE OF ADDRESS INFORMATION <br /> .�.LC <br /> MAILING OR STREET ADDRESSy �� ✓ bw si'*" Q INDIVIDUAL I--] LOCAL-AGENCY f�STATE-AGENCY <br /> JOCK, Z.S� CORPORATION PARTNERSHIP E=]COUNTYAGENCY FEDERALAGENCY <br /> CIN NAME I SLATE ZIP CODE HONE a WITH AREA CODE <br /> `Rci K&I QA qi4 sto 2-*s <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - Q c( <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THEM OD(S) USED <br /> ✓bo`bbgkale 1 SELF-INSURED I�2 GUARANrEE 3 INSURANCE <br /> O SURETY BOND <br /> 5 LETTEROFCREDIT <br /> O 8 E%EMPnON O Ie OTHER <br /> V1. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unles box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.O III.Q <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED B SIGNED) OWNERS TITLE DATE MONTWDAY/YFAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY p JURISDICTION a FACILrTY t()3g0 <br /> IT—] a � lon 4 <br /> LOCATION CODE -OP77ONAL CENSUSTRACTa - T/ONAL SIIPVISOR-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 /> FORMA(393) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUNn STORAGE TANK REGULATIONS <br /> FONNIS <br />