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V <br />aWa - <br />� s� <br />STATE OF CALIFORNIA .` '� <br />0 <br />STATE WATER RESOURCES CONTROL BOARD W .,�� � n Q <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A >a �, , <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE °axoea+�a <br />MARK ONLY O t NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSEDqTE <br />ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 1 x-7 <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />oRA 0.4 `CITY NAME <br />, <br />NAME OF OPERATOR <br />t�CT.'1� ✓ , e-" <br />ADDRESS _ <br />`ZSoO Gd/. Got AV%.nw—��9G <br />NEA EST CROSS STREET <br />PARCEII(OPfgNAW <br />CITY NAME <br />/a417: <br />STATE <br />CA <br />ZIP CODE"� <br />"ZjrZyV <br />0 SITE PHONE#WITH AREA CODE <br />�] 333-9& <br />pppp <br />✓ �x CORPORATION INDIVIDUAL I= PARTNERSHIP LOCAL -AGENCY I� COUNTY -AGENCY' I� STATE -AGENCY' O FEDERAL -AGENCY <br />TO INDICATE <br />\\ DISTRICTS' <br />' If owner of UST is a public agency, corplele the following: name of Supen•lsor of division, section, or oHica which operates the UST <br />TYPE OF BUSINESS OAS STATION 2 DISTRIBUTOR <br />0 ✓ IF INDIAN <br />I# OF TANKS AT SITE <br />E. P. A. I. D. a (optional) <br />3 FARM 0 4 PROCESSOR [=] 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optlonal <br />DAYS: NAME (LAST, FIRST) PHONE I WITH AREA DE <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />vGh9+9 1 ' �Zr»i� ? <br />NIGHTS: NAME (LAST, FIRST) PHONE I WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE a WITH AREA CODE <br />30I P A G-OL✓/_1 ,4 <br />CORPORATION PARTNERSHIP 0 COUNTY-AGENCYQ FEDERAL -AGENCY <br />It. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME Ci/Y SSG/I6L' C�l�- <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADORES <br />✓ box lo Indicate INDIVIDUAL (] LOCAL AGENCY [__1 STATE -AGENCY <br />✓ box to Micas O INDIVIDUAL ElLOCAL-AGENCY Q STATE AGENCY <br />30I P A G-OL✓/_1 ,4 <br />CORPORATION PARTNERSHIP 0 COUNTY-AGENCYQ FEDERAL -AGENCY <br />CITY NAM <br />F ho, <br />STATE <br />CQ <br />STA <br />ZIP COD <br />90 0% <br />HONE WITH AREA CODE <br />�452- 6Zvc> <br />.� <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to Micas O INDIVIDUAL ElLOCAL-AGENCY Q STATE AGENCY <br />30I P A G-OL✓/_1 ,4 <br />CORPORATION PARTNERSHIP Q COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />,/U_CL,e,4 lbl-Z,s <br />STATE <br />CQ <br />ZIPCODE <br />9i3o <br />PHONE # WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER -Call (916) 322-9669 if questions arise. <br />TY (TK) HQ M44- O 6 L <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED <br />✓ box 0 Ric ate [:::] t SELF INSURED L__j 2 GUARANTEE L_J 3 INSURANCE 0 d SUflETY BOND <br />O 5 LETTEROFCREDIT I=1 6 EXEMPTION E-:1 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: L[71 I. ❑ <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 & SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # FACILITY # I <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION <br />UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br />OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />FORM A (353) 0 <br />0 <br />FOR0033AA7 <br />