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• STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD <br /> • <e*pOR <s <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> o <br /> o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT <br /> ONE ITEM ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT <br /> ❑ 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> iier) V /4 A`S NAME OF OPERATOR <br /> ADDRESS L �[ <br /> L CITU NAME NEAREST CROSS STREET PARCEL M(OPTIONAL) <br /> STATE ZIP CODE <br /> ✓ PDX C �_ CA SITE PHONE M WITH AREA CODE <br /> TO INDICATE D CORPORATION 0 INDIVIDUAL O PARTNERSHIP Q LOCAL AGENCY <br /> TYPE OF BUSINESS DISTRICTS 0 COUNTY AGENCY Q STATE-AGENCY FEDERAL#GENCY <br /> ❑ 1 GAS STATION ❑ 2 DISTRIBDTDfl <br /> ❑ <br /> RESERVATION MOF TANKS AT SITE E.P.A. I.D M(optional)3 FARM O 4 PROCESSOR ❑ 5 OTHER OOq TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> OAVS: NAME LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) <br /> PHOIifIMITH AREA CODE NIGHTS: NAME(LAST,FIRGT) <br /> m k G� -07,x< <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME <br /> ,EJ­v y\_c(_ c / CARE OF ADDRESS INFORMATION <br /> MAILING OR STRET ADDRESS ( - <br /> �L O t IJV I< 3lo C �] ✓box bk <br /> inkw Q INDIVIDUAL 0 LOCAL-AGENCY Q <br /> CITY NAME �p O / E:]CORPORATION (] PART AS STATE-AGENCY <br /> COUNTY-AGENCY V_ t56 I STAT ' ZIP CODE 0 FEDERAL#GENCY <br /> I v / '�J �! ` PHONE M WITH AREA CODE <br /> III. TANK OWNER INFORM TION-(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> ^ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS U U3— — <br /> ✓ box blMkale INDIVIDUAL 0 LOCAL-AGENCY O STATEAGENCY <br /> CITY NAME SO CORPORATION ED PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> ZIP CODE PHONE M WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4 4 - ? � <br /> V. PETROLEUM UST FINANCIAL RREESSP"OON�SIBBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bintlkale 1 SELF INSURED C:1 2 GUARANTEE <br /> 5 LETTER OF CREDIT ]6 EXEMPTION 0 3 IN NCE 0 M SURETY BOND <br /> OTHER`� <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is c cked. <br /> CHECK ONE BOX INDICATING WHICH ABOVEADORESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> I.❑ II. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,qND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> APPLICANTS TITLE <br /> DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> 7_OpIIO <br /> Y u JURISDICTION M <br /> - FACIL�-�IeUT-0 6 1 S <br /> ___ _ __ __ �LOCATION ICENSUSTRACTM --- <br /> OPTIONAL I SUPVISOR-DISTRICT CODE -OPTIONAL — <br /> TA(1 FORM MUST BE ACCOMPANIED BY AT LEAST(1 Oq MORE PERMIT APPLICATION• FORM 8,UNLESS IS A CHANGE OF ITE INFORMATION ONLY. <br /> FORMAI 1z-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> % . 011A R6 <br />