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• � 't6 e C <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD + ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A : s <br /> COMPLETE THIS FORM FOR EACH FACILRY/SITE <br /> MARK ONLY O t NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE Z <br /> I. FACILTTYISITE INFORMATION 8 ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS C. NEAREST CROSS STREET PAR CEL 0(OPTIONAL) <br /> CITY NAME -- STZI�OESITE <br /> —PHONE S WITH AREA CODE p <br /> v BOX <br /> TOINDICATE O CORPORATION D INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY COUNTY AGENCY' O STATE-AGENCY' Q FEDERALAGENCY' <br /> 'If owner of UST Is a public agency,mrrplele the following: m <br /> nae of Supervisor of tllvlebn,section.DISTRICTS'n,or of oe which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR / IF INDIAN a OF TAN IS AT SITE E.P.A. I.D.M(gNwnal) <br /> 3 FARM TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: ryryAAMEµµAAST,FI ST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> vYJ�,.l.ra� <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE R WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED 01L-.> <br /> 000/a <br /> NAMEG CARE OF ADDRESS INFORMATION <br /> /i y c>c late /L�,� 0 ' , <br /> MAILING OR STREET ADDRESS ^��` �� ✓ Eoz bintlaale � INDIVIDUAL O LOCALAGENCY O STATE AGENCY <br /> 12-1,— /`] — S i�•--y�� 11_z S_11e L O CORPORATION [:::) PARTNERSHIP [—I COUNTY-AGENCY FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> Low i � -:7 33-688 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER / CARE OF ADDRESS INFORMATION <br /> G I / OG lj��/ � � gPi'.q/ D <br /> MAILING OR ST ET ADDRESS ✓ box to in icate INDIVIDUAL I= LOCAL AGENCY D STATE-AGENCY <br /> CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY L-] FEDEPALAGENCV <br /> CITY NAME STATE ZIP CODE PHONE A ITH AREA CODE <br /> Goo � 95� �333 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- -L�� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHODS) USED <br /> boa blnEkz4 I SELF INSURED l=2 GUARANTEE [-1 3 1NSURANCE O 4 SURETY BOND <br /> l� 5 LETTEROFCREDIT = 6 EXEMPTION 0 N 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: 1.0 IL D III,O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED A SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY 2 9 O A <br /> COUNTY# JURISDICTION If <br /> FACILITY <br /> LOCATNJN CODE -OPTIONAL CENSUS—TRACT a -IWTIONAL SUPyISOLR-UIS I HOT CODE -OPTpNAi <br /> o Z3 •� s <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS 18 A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> i0110037Afl7 <br />