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-�eOU- <br /> C <br /> STATE OF CAUFORMA .` '; <br /> STATE WATER RESOURCES CONTROL BOARD ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A s <br /> COMPLETE THIS FORM FOR <br /> EACH FACILITY/SITE ���.o.��' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT NCI 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFA ILITY NAME NAMEOFOPERATOR <br /> A DRESS NEAREST 9ROtS STREET PARCEL*(OPTIONAU <br /> S It 053-I,/D - Zd <br /> CITY NAME STATE ZIP CODE SITE PHONE*WITH AREA CODE <br /> /,olJ CA "P-5Z�b <br /> T NOICATE O CORPORATION t3mDIVIDUAL I__1 PARTNERSHIP ED LOCAL-AGENCY O DOUNTY-AGENCY' O STATEAGENCY' ED FEDERALAGENCY' <br /> DISTRICTS' <br /> N Amer d UST Is a public agency,aomplele the follomng:name of Supervisor of divisk n,section,m office which opmalea the UST <br /> TYPE OF BUSINESS F-1t GAS STATION ❑ 2 DISTRIBUTOR R SERVATION A OF TANKS AT SITE E.P.A. I.D.*(gollana) <br /> 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER ORTRUSTLANDS l <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE*WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE*WITH AREA CODE <br /> S�GvvZ -03 O <br /> NIGHTS: NAME(LAST.FIRST) ONE*WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME � CARE OF ADDRESS INFORMATION <br /> MAILING OR ST T OflES3 box biMkaw E�] INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP = COUNTY-AGENCY E3 FEDERAL-AGENCY <br /> CITU NAME STATE RCO <br /> 5 DOeW7039/'� <br /> III. TANK OWNER INFORMATION-(M ST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> SiG vEi moi- t� <br /> MAILING OR STREET ADDRE 5 ✓ boa birdkma 0 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> Z, CORPORATION 0 PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY� STATE C7FZIP CODE _ / HON�1 -70,THAREODE�� <br /> sKb <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(91//6)322-99/6669 if questions questions arise. <br /> TY(TK) HQ M44- -L_[_]_i ] _] ] <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ twx b iMkaie 0 1 SELF-INSURED ❑2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> 0 5 LETTEROFCREDIT =6 EXEMPTION 0 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.Ile�o xv IL 14 III.❑ <br /> ` <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) OWNERS TITLE DATE MOfNTWDAYNEAR <br /> LOCAL AGENCY USE ONLY o�3?-7— <br /> COUNTYIN JURISDICTION* FACILFrY• <br /> pR <br /> Tom <br /> LOCATION CODE -OPTIONAL CENSUS TRACT*-OPTIONAL SUPVISOR-DISTRICT CODE -OPTION& <br /> 1 y� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS 1S A CHANGE OF SITE INFORMATION ONL�� <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKW / Y <br /> FORM A(393) -� FORDM3MR7 <br />