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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD �o�p <br /> yuy.- f r <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM <br /> A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT <br /> ONE(TEM0 3 RENEWAL PERMIT <br /> 2 s CHANGE OF INFORMATION <br /> INTERIM PERMIT a 4 AMENDED PERMIT 7 PERMANENTLY c <br /> I. FACILITY/SITE INFORMATION&ADDRESS- ❑ 6 TEMPORARY SITE CLOSURE <br /> COM <br /> DBA OR FACILITY NAME ,Q {MUST 8E PLETED) <br /> �� �" `��S •�!'`La + ,1�3 NAME OF OPERATOR <br /> AD DRESS <br /> T 14 4:V, <br /> SIC 7 9 i/ P. NEA RESTCROSSSTREET <br /> CITY NAME !` �" <br /> ,�/��•-��g� PARCEL x(OPTIONAL) <br /> STATE /9 7-41 - 3 <br /> — 3 <br /> ✓ taDx E <br /> ZIP CODE PHOE/WITH AREA CODE <br /> TO INDICATE IifrCORPORATION INDIVIDUAL71 <br /> 'H owner d UST Is a public agency,ca �PARTNERSHIP � LOCAL-AGENCY <br /> mplele Iha following;name of Supery ear of division,seclbn,oIS DISTRICTS <br /> wh ch COUNTY,AGENCY• <br /> TYPE OF BUSINESS d STATE-AGENCY' D FEDERAL-AGENCY• <br /> 1 GAS STATION � 2 DISTRIBUTOR operates the UST <br /> 0 3 FARM l� ✓ IF INDIAN ;s OF TANKS AT SITE E.P.A. L D.s <br /> 0 4 PROCESSOR 5 OTHER RESERVATION (option <br /> aP) <br /> EMERGENCY CONTACT PERSON (PRIMARY) OR TRUST LANDS IVA <br /> DAYS; NAME(LAST,FIR sJT � EMERGENCY CONTACT PERSON (SECONDARY - <br /> MOO�P.h .�T HONE M <br /> fWITH AREA CODE DAMS. NAME(LAST,Fl ST)�Q/Ltr HONE s W� dPCIORgt <br /> NIGHTS: NAME(LAST,FIRST) PHONE q WITH p CODE Q S/ Vl9j II Lam. 'JITTHH AREA CODE <br /> NIGHTS: NAME(LAST FIRS 2 75;n <br /> ��4 PHONE A WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- <br /> NAME 'BE COMPLETED <br /> '✓�' `�` y /'�IQQ�� CARE OF ADDRESS INFORMATI07V <br /> MAILING STREET RESS /tlf e2, <br /> / •U- X 4 7 ✓box b Indicate I ] INE VIDU4 L <br /> CITY NAM 92 cORPORAPON O p�TNERSkIP 0LOCAL-AGENCY [�STATE-AGENCY <br /> G STAT ZIP C© �J COUNTY-AGENCY FEDERAL-AGENCY <br /> S-3, ,Cl iy PHONE x W ATH AREA CQDE <br /> Ili. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF O ER <br /> 7;CARE �pDR MATION <br /> LMAILING Oq,STgEET ADDRESS •�+�! � + ��_�� <br /> , � j � Iwx to ndicale a INDIVIDUAL <br /> � LOCAL-AGENCYNAME' , l URPOR ] COUNTY-AGENCY d STATE-AGENCY <br /> T ZIP CObE FEDERAL-AGENCY <br /> PHONE M WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise �.�.5=�� � <br /> TY(TK) HQ 44- - p e� <br /> V. PETROLEUM UST FINANCI ESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓hoxbirMcateI I SELF-INSURED <br /> 5 LETTEROFCREDIT 0 2 GUARANTEE 0 3 INSURANCE <br /> 11:16 ExEMPTIflN 0 gg OTHER _�1-2°56AETY&OND <br /> VI. LEGAL NOTIFICATION AN ILLING ADDRESS Legal notification and billing will be sent to the tants owner unless box I or II is the <br /> CHECK ONE BOx INDICATING WHICH AB VE DRESS SHO D BE USED FOR LEGAL NOTIFICATIONS AND BILLING; Cked. <br /> THIS FORIN HAS BEEN COM ,(_ I'0 II.� lu• <br /> D DE ENALTY OF pE,q,/URY AND TO THE BEST OF MY KNOWLEDGE,f5 TRUE AND CORRECT <br /> pwNER'S NAME(PRINTED d SIGNED) <br /> ' 7,k= <br /> � OWNER'S TITLE <br /> DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY 3 3/ 97 <br /> COUN7Y# JURISDICTION i <br /> 64 FACILITY#b0()q 1 <br /> LOCATION CODE -OPrKW4L CENSUS TRACTS -OPTlpNA1 ` <br /> 9LFPVISOR-DISTRICT CODE -OpnONA1 n <br /> THIS FQRIYI MUST BE ACCOMPANIED !EAST{i)OR <br /> OWNER MUST FILE THIS <br /> FOO MORE PER APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF E INFORMATION ONLY. <br /> FORM A(3190} S RM WITH THE SIT <br /> LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATVa <br /> 0 0 FOR=3A-R7 <br />