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a.0-. e <br /> STATE OF CALIFORNIA ` <br /> STATE WATER RESOURCES CONTROL BOARD 3y <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W m� 40 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> 3Z lLA5c)^l <br /> ADDRESS � <br /> NEAREST CROSS STREET PARCEL I(OP`rIONAU <br /> G`Ei.iTEir2 <br /> CITY NAMME '/� � STATE I ZIP CODE SI PHONE A WITH AREA CODE <br /> /C CA `�_ 40 <br /> I/ Box <br /> TO INDICATE Q CORPORATION INDIVIDUAL = PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS I� I GAS STATION 2 DISTRIBUTOR '/ on INDIAN J#OF TANKS AT SITE E.P.A. I.D.x(optimal) <br /> Q 3 FARM Q, 4 PROCESSOR Q 5 OTHER RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECO DARY)-optional <br /> DAYS: NAME(LAST,FIRST) P NE M WITH AREA CODE DAYS: NAME(LAST,FIRST) 'rJ. <br /> F/�n/.;✓�yliSth� � Y. /4�(n- S/ 1"71h�lvw6e Win/ ai� <br /> C <br /> NIGHTS: NAM (LAST,FIRST) HON N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) - <br /> G rJ7Z �7 <br /> /tW1 JQ 0VOAE / t CODF <br /> !7 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Awl vG�ct; C EI-10 S <br /> MAILING OR STREET ADDRESS /- ✓ box iomdkat! Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> O /130)c ((/Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHON s WITH AREA CODE <br /> 49,71f 51.4 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Aeev /7 c T 64::3E if <br /> MAILING OR STREET AD05RESS ✓ box ioind"is <br /> aP Q INDIVIDUAL Q LOCAL-AGENCY QSTATE-AGENCY ox 49 JeCORPORATION Q PARTNERSHIP Q cOUNTY•AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STT ZIP CODE P NE N WITH AREA CODE <br /> Ap-��"S1A © � s-6j" 7 ��0--�t7 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 144 -'C 1,0 10 1j' 0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to w6cale 1 SELF-INSURED Q 2 GUARANTEE Q 7 INSURANCE Q 4 SURETY BOND <br /> QI 5 LETTEROFCREDIT Q 6 EXEMPTION IQ 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.7] II.�—. III. <br /> THIS FORM HAS BEEN COMP"D U DER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 8 SIGNATU ) APPLICANTS TITLE DATE ONTH/DAY/YEAR <br /> e.`E'/ <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION u FACILITY u <br /> LOCATION CODE -OPTIONAL CENSUS TRACT a -OPTIONAL SUPVISOR•DiSTRICT CODE •OPTIONAL <br /> i <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(5-91) FOR0093A-5 <br /> Lt V4/5-3 l9 y <br />