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y� Need a <br /> STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND 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 ❑ 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM E] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) pYd3 <br /> orQR FA ILITY NAME NAME OF OPERATOR <br /> ( Kc P1er�i , at, C <br /> ADDRESS _J � N ST CROSS 5�7EET PARCEL t(OPTIONAL) <br /> L by I��% U 26 <br /> CITUL tA STATECA ZIP C�E SITE PHONE R WITH AREA CODE <br /> V,BOX (]CORPORATION 0 INDIVIDUAL C3 PARTNERSHIP O LOCAL-AGENCY 05CWNTY.AGENCY' E::] STATE-AGENCY* E::] FEDERAL-AGENCY- <br /> TOINDICATE DISTRICTS <br /> 1oxsw01 UST apbeo egsncl.ot"kb be tollowng:name of supeMvurol dMeion,section aoR¢e which operates the UST <br /> TYPE OF BUSINESS I GAS STATION ❑ 2 DISTRIBUTOR ❑ REV IF INTION <br /> ry7 #OF TANKS AT SITE l) <br /> E P.A. I.D.R(optiona <br /> ❑ 3 FARM ❑ 4 PROCESSOR 1� 5 OTHER OR TRUST LANDS Z <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME e.FIR P�r PHONE R WITH AR CQ DE DAYS: NAME(LAST,FIRST) PHONER WITH AREA CODE <br /> NIGHTS: E(LA ,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE R WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME}� _ CARE OF ADDRESS INFORMATION <br /> N STREET SS e' boxlondrAle INOMOUAL LOCAL-AGENCY STATE-AGENCY <br /> lou <br /> 1Mc� �e FO, W6-7703,& (]CORPORATION <br /> UG( O PARTNERSHIP =COUNTY-AGENCY C--] FEDERAL-AGENCY <br /> C/' Ao $ <br /> a BTATy v ZIPW Jam.. HDNE# ITH�EA CDDEb r <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CA <br /> NAII4SCFAwo / �n4qvA� CARE OF ADDRESS INFORMATION <br /> MAIILINGLfOIMSSTREUDij��$ p� (� T�y� n-7/L2 .1boxlondirAla INDMCM- <br /> OUAL �LO -AGENCY [—ISTATE-AGENCY <br /> tL/ O CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY A Ef 5h STA�pL ZIP 5SS-7 PHONE#WITH'AR- E <br /> (071 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER/`Call(916)322-9669 if questions arise. Sf <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box loincloth, Q 1 SELF-INSURED EK 2 GUARANTEE =3INSURANCE =4 SURETY BOND 0 5 LETIEROFCREDIT =6 EXEMPTION O 7 STATE FUND <br /> O8STATE FUND&CHIEF FINANCIAL OFFICER LETTER OBSTATE FUND&CERTIFICATE OFDEPOSIT 010 LOCAL GOVT.MECHAMSM = 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 AD ESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ II. III.❑ <br /> THIS FORM HAS BEEN COMP UNDE PENALTY OF PERJURY,AND TO THE BEST OF MYKNOWLEDGE,IS TRUEAND CORRECT <br /> AME(PRINTED a s NA � T KOWNER'S DATE ��/1�� MONTHIDAV/Y <br /> Q c4ul 'I ow e l �C'(s <br /> LOCAL AGENCY USE ONLY Vrj <br /> COUNTY# JURISDICTION# FACIIJTY# <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 /> �%� <br /> FORMA(695) <br /> OWNER MUST FILE THIS FORM,"'-4 THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU�TORAGE TANK REI ULATION�^ f- <br /> Jr G� <br /> 1 a16 ilo--� <br />