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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD � <br /> 12 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> Il�� <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE r•cifoRr <br /> MARK ONLY F7 1 NEW PERMIT 0 3 RENEWAL 'PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO SITE <br /> ONE REM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR ACILITY ME ` + NAME OF OP RATO <br /> fit: �C \f © j -S c__ <br /> ADDRESS � qq NEARE T C 0 STREET PARCEL it(OPTIONAL) <br /> t QS) JV ✓`� I SCD 4 <br /> CITY NAME STATE ZIP C DE SITE PHONE a WITH AREA CODE <br /> CA 5zc:;,5 <br /> ✓ BOX PORATION l� INDIVIDUAL i7 PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY' <br /> TO INDICATE DISTRICTS' STATE-AGENCY' FEDERAL-AGENCY" <br /> 11 owner d UST Is a public agency,complete the fo1owing:name o1 Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN IN OF TANKS AT SITE E.P.A. I.D.0(optional) <br /> RESERVATION <br /> 3 FARM 0 a PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NA E(LAST FIRST) PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST} PHONE s WITH AREA CODE <br /> -,C) V4r �06 3- 6 y3 <br /> NIGHTS: NAME(LAST,F!R T) PHONE A WITH AREA CODE NIGHTS: NAME{LAST,'FIRST) PHONE A WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME -jaCARE OF�IDDRESS INFORMATION <br /> GIC 4/U J1'f, <_ <br /> MAILING OR STREET ADDRESSr ✓ box b indicale 0 INDIVIDUAL ® LOCAL-AGENCY STATE-AGENCY <br /> ILl 7-61L0"A Aif Q CORPORATION ] PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY 7ME STATE ZIP CODE PHONE X WITH AREA CODE <br /> ,re s r Lo LL/Z Z�[ y L/ z-2 L. <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicals 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> C]CORPORATION [] PARTNERSHIP I] COUNTY-AGENCY [__1 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boxbindicate lamI SELF-INSURED 2 GUARANTEE URANCE 0 4 SURETY BOND <br /> L__J 5 LETTEROFCREDIT G EXEMPTION a 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: L I 141. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTFVDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION FACIL.TAY <br /> LOCATION CODE •OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR.D T CODE oP <br /> 23 - ,3 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORlIIATION ONLY. <br /> FORM A(3193) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGJr TANK REGUFOR0003 <br /> LA � <br /> �/� 11�i7 <br /> 1 � <br />