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• STATE OF CALIFORNIA • <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> ie <br /> MARK ONLY 111 NEW PERMIT ❑ 3 RENEWAL PERMIT [1] 5 CHANGE OF INFORMATION c•"o- ' <br /> ONE ITEM E:12 INTERIM PERMIT ❑ T PERMANENTLYV C SITE <br /> ❑ 4 AMENDED PERMIT E::] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) D <br /> OBA OR FACILITY NAME <br /> 4 / X,Gn <br /> P- _ aK NAME OF OPERATOR <br /> ADDRESS % <br /> _5A NEAREST CROSS STREET L) <br /> PAflCEIp(OPTIONA <br /> CITY NAME LL++ /PA /< <br /> GST STATE ZIP CODE TE PHONE X WITH AREA CODE <br /> ✓BOX QCORPORATION <br /> TO INDICATE I�INDIVIDUAL I� PARTNERSHIP LOCAL-AGENCY O COUNTY-AGENCY' <br /> ED DISTRICTS STATE-AGENCY• O FEDERAL-AGENCY' <br /> 0O"rof UST'a a public agenry,oDrMlete the lNlowng.name d supervisor of division,sepbn Or OXke e41tll Operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2DISTRIBUTR ✓IF INDIAN X OF TANKS AT SITE E.P.A. L D.X(Optinal)❑ 3 FARM 4OSOR <br /> j7r 5 OTHERRESERVATION 1 <br /> OR TRUSTIANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> D <br /> AYS, ME(LAST,FIi�BT) PXON X WITH AREA CODE <br /> T'� G- r2j9DAYS: NAME(LA$T,FIRST) PHONEp WITH AREA CODE <br /> AME(LAST,FIRS'N PHONE X WITH AREA CODE�Q J NIGHTS: NAME(LAST,FIRST) PHONE X WITH ARRA CODE <br /> 1 /Vis — �p. <br /> If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME <br /> G� CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADUMLSS <br /> tea ' S. SGS S7� ✓ bOplo vidrale Q INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CITY NAME CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> G 47�T BTA��. ZIP HONE WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> -4.8= 1 ���� CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> p O �0 //�O ✓ bo tontl ate Q INDMDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> CITY NAME ORPORAnoN O PARTNERSHIP COUNTY-AGENCY E:1 FEDERAL-AGENCY <br /> liC.y�7� <br /> STATEj ZIPCODEU P ONEX ITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(9166)322.9669 if questions arise. <br /> TY(TK) HQ 4 4- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box WW ate O 1 SELFINSURED ED 2 GUARANTEE Q 3INSURANCE E—)4 SURETY BOND Q 5 LETTEROFCREDn <br /> TM <br /> ED8STATE FUND B CHIEF FINANCIAL OFFICER LETTER OSSTATE FUND&CERTIFICATE OF DEPOSIT 018 LOCAL GOVTMECHANISM OOOTHEFL.. <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ III,❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTYOF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNER'S NAME(PRINTED 8 SIGNATURE) TANK OWNER'S TITLE <br /> DATE MONTHiDAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY X JURISDICTION X FACILITY X <br /> LOCATION CODE -OPTIONAL CENSUS TRACT M •OPT/ONAL <br /> p L5 8,0 SUPVJ$pq�TRICT CODE -OPT/ONAL <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(6-95) OWNER MUST FILE THIS FOR jr THE LOCAL AGENCY IMPLEMENTING THE UNDERGROIE TANK REGULATIONS <br />