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•cW^ � <br /> n <br /> STATE OF CALIFORNIA � <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A . o <br /> COMPLETE THIS FORM FOR EACH FACILI TYISITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ S CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED <br /> SITE <br /> TJONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAME OF OPERA TR <br /> DBA OR FACILITY NAME S. ffoI.sJ$QAer, <br /> PAACEL#(OPr1ONW <br /> ADDRESS I NEAREST CROSS STREET <br /> Z / k`TONE STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> CITY NAME CAOM�Oj-6- �Q <br /> LOD 'T !7� <br /> TOINDCATE CORPORATION 0 INDIVKIUAL PAIiTNFASHIP 0 LOCAL <br /> DST�AGENCY 0 COUNry ASENCY' ESTATE-AGENCY' O FFDERAL#OENCY' <br /> • <br /> Vo r cIUST N apublic agency,mn1Pk1N W 10Am*V:narrw d Supewleor of division,section,or office which OPOMW the UST <br /> TYPE OF BUSINESS ❑ I GAS STATION 2 DISTRIBUTOR ❑ ✓ IF INDIAN a OF TANKS AT SITE E.P.A I.D.t(oprknNi <br /> ❑ RESERVATION <br /> 3 FARM ❑ 4 PROCESSOR ❑ S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-Optional <br /> DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREACODE DAYS:NAME(LAST,FIRST) PHONE$WITH AREA CODE <br /> D l.1/ rj TEV,CR C 9 '� PHONE a WITH AREA CODE <br /> NKIHTS: NAME(LAST.FIRST) PHONE$WITH AREA CODE NIUMW NAME(UST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFO�RTMYATION <br /> Et74 F� �//f� �� I�1[a�.T� �E� y-V/A <br /> MAILING OR STREET ADDRESS ✓ box bN#icNM O INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> �/vE Su/7—E 7oG O CORPORATION =PARTNE SHIP 0 COUNfY#GENCY l�FEOEML-AGENcv <br /> CITY NAME STATE ZIP CODE P NE a ITH AREA CODE <br /> p�4 I-/AS T'x -75Z 6 � -7oZ_ Z <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATIO <br /> MAILING OR STREET ADDRESS ✓ bosbkdC" INDIVIDUAL [___l LOCAL AGENCY STATE-AGENCY <br /> /LZzL F / r- 0.ev//L�_ _-CA6",re ^JOp (]CORPORATION PARTNERSHIP =COUNTY AGENCY 0 FEDERAL#GENCY <br /> CITY NAME STATE ZIP CODEHON <br /> ✓�4G Z5/ 7,10;Z*05.9 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ hm bYdkw O 1 SELF-INSURED O 2 GUARANTEE O 3 INSURANCE O A SURETYBOND <br /> O 5 LETTEROFCREDIT O a EXEMPTION = W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 11.[=] Ill.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED A SIGNED) OWNER'S TITLE DATE MONTHDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILrTY# 7jN9�,,- <br /> LOCATION CODE-OPTIONAL CENSUS TRACT$ OPTIONAL 9UPVSOR-DISTRICT CODE -OPTIONAL <br /> SZo Z_ l/ D <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESSTHIS IS A CHANGE OF SIT911MFDRMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKINS <br /> FORM A(393) FOROMM417 <br />