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' � aaoua e c <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 'g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO D SITE /L <br /> ONE ITEM O 2 INTERIM PERMIT Q4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) 0 Ory <br /> D IPTCILIITYPAME V(Mnc NAMEOFOPERATOR <br /> ADDRESS <br /> ��r� NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> qv <br /> Wl <br /> Z <br /> CIMBOSTATE IP DE TE PH NE#WITH AREA CODE <br /> CA Ct53 6 7-3q-12,15" <br /> TO DIICCATE IM CORPORATION INDIVIDUAL O PARTNERSHIP D LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY (] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O i GAS STATION = 2 DISTRIBUTOR RESERVATION IF INDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> Q 3 FARM O 4 PROCESSOR LX 5 OTHER OR TRUST LANDS 7/ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> Inn � ZV7-t11sPHONE a WITH ARFA <br /> NIGHTS: NAME ILAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAMB� p/(��� ��� A." / CARE OF ADDRESS INFORMATION <br /> MAILING]ORISTREET <br /> /ADD 5 {A/m 1/.1/rle ✓ pev to Indicate 0 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> )wnl S. 1CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITU - C A STAJE# Z��; PHONE21 L WITH AREA-OI 7,I r <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) �� / J S <br /> NAM FOvy;ER � /,S CARE OF ADDRESS INFORMATION <br /> �(D-LII II!A <br /> MAILING <br /> /.OR�STREET ADD5FJ¢S ^�1 ✓Eox mintlicale 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP l= COUNTY-AGENCY FEDEMLAGENCY <br /> CITUN ME SAE ZIP ODE HONE# ITH AREA CODE <br /> w LQ 'z �53�� Z64) 239- 12 f 5 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if quesfions arise. <br /> TY(TK) HQ F474_]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 0 2 GUARANTEE 0 7 INSURANCE 0 4 SURETY BOND <br /> O 5 LETrEROFCREDT 6 EXEMPTION 0 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. II, III.0 <br /> THIS FORM HAS BEEN COMP ETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> AP LICANTS NAME(PRINTED&SIG PPLICANTS TI E DATE ONTH/ AVIYEAR <br /> IkGh L�i e� crw <br /> f 'nr xck 9 <br /> LOCAL AGENCY USE ONL <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVI30R-DISTRICT CODE -OPT/OAUL <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) FOR007iA5 <br /> 0 <br />