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r' <br /> �Z <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD '•- ��\� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Nn <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION CK T PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME t R, -)q <br /> �,/J)/)q NAME OF OPERATOR <br /> A10502 I' Crl D {C/� ' -^�- NA Y NEA EST r[/11r EET PARLIEL iIIXUL) <br /> CI OGkfiOn STATE ZIP ^'5 SITE PHONE N WITH AREA CODE <br /> ^ <br /> ✓ Box 19 CORPORATION Q VIOMWAL O PARTNERSHIP O LOCAL-AGENCY O WUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS - <br /> •tl6MNrd UST b a Piltl6e agH1ry,mmOMb tlMbbnnq PaP.d supweard 6veoli,sadim aaUo xNii{I oNran 01A UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓IF INDIAN t OF TANKS AT SITE E.P.A. I.D.I(0pb W9 <br /> RESERVATION <br /> 3 FARM O A PROCESSOR O 5 OTHER OR TRUST LANDS `J <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) P NE A WITH AR CODE DAYS: NAME(LAST.FIRST) PHONE A WRX AREA CE <br /> 011E <br /> ooze Z� - 21 <br /> NIGH : NAME(LAST,FlR PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE w WITH AREA CODE <br /> E n - z <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CME OF ADDRESS INFORMATION <br /> •le k �tvr�s Ir.c - <br /> MAILINGORSTREETADDRESSG-� (� �✓(Imw^ m Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGFN(."l <br /> . (�. v� ✓2DU� C<CDRPdUTION a PARTNERSHIP o COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY RSD t"inl� STATE ZjP_CAD€� PHONEA WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) ((J"�!✓17 <br /> N EOFQWNER CARE OF ADDRESS IN RMATTCN <br /> IGIe K m ��an� C,�o�din�lor <br /> MAILING OR STREET ADDRESS a ✓yemroitlYAe Q NDMDUAL Q LOGY-AGENCY Q STATE.AGENCY <br /> ps D• U� K*a,0RPORATION PARTNERSHIP Q COUNTY-AGENCY a FEDERAL AGENCY <br /> CITY AME T STATE ZIP CODE PHONE 6 WITH MEA CODE <br /> � <br /> ventx 2 -2»-L31'1 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 44- - 7 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓W.0 vi6CMA 1 SRI SURED =2 GUARANTEE O 3 MUPANCE Q A SURETYBONO 5 UFTTEROFCREDIT Q 6 EOAPM7N =T STATE RING <br /> Q 6 STATE FUND&CHIEF FNAN(JALOFFICER LETTER O 9 STATE FUND 6 CERTIFICATE OF DEPOSIT O 10 LOCALGOVT.MEON.WISY 0 99 OTHFA <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is dTe&e�d,.� <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[—] II.❑ UL 1.t <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT ���--VVY" <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAWYEAR <br /> Za) 96�2flinp NF tAL Llys (rtc -Fr <br /> LOCAL AGENCY USE ONLY Z <br /> COUNTY M JURISDICTION 6 /ri FACIIJTY a <br /> 23 foSlEl O 8 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B.UNLESS THIS IS A CHANG OF SA INFORMATION ONLY. <br /> OWNER MUST FILE THIS FOv' TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRPe_ STORAGE TANK REGULATIONS <br /> FORM A("5) <br />