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'LyOVe <br /> STATE OFCALIFORISA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY t NEW PERMIT O 3 RENEWAL PERMIT ��5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT O 4 AMENDED PERMIT 'QI6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION III ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> 0 <br /> ADDRESS NEAREST 91FICSSS FEET PARCEL r(OPTIONAL) <br /> Ll/oG oA -Z <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> e CA <br /> TO INR RTE O CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' STATE-AGENCY' 0 FEDEML-AGENCY' <br /> DISTRICTS' <br /> 'II caner d UST Is a public agency,complete the following:narne of Supervisor of division.section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTORgESERVADDIIAN ON s OF TANKS AT SITE E.P.A. I.D.#(Cphona# <br /> 0 3 FARM Q 4 PROCESSOR Q 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING STREET ADD E S ✓ boabinERals = INDIVIDUAL = LOCAL-AGENCY STATE-AGENCY <br /> '-770 1 'S1.4k CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAMEBTATE ZIP COD P ONE# ITH AREA CODE <br /> 5 356 Z�l_15215-650v <br /> III. TANK OWNER NFORMATION-(MUST BE COMPLETED) <br /> NAME OOWNER <br /> �� <br /> a` p Q CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS .a,�//��//�� ✓ bNbindcate E_—] INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> A.�72f O CORPORATION 0 PARTNERSHIP E=1 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE ,PHONE WITH AREA CODE <br /> 9 <br /> aEs r� M 6-3 Z6 y <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4]-4-]-ELI= <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓y„bAbbay D t SELF INSURED D 2 GUARANTEE 0 3 INSURANCE 0 A SURETY BOND <br /> 0 5 LETfEROFCREDIT 6 EXEMPnON 99 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.W II.[�] Ill.E <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY IT JURISDICTION# FACILTrY• <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR•D ICTCODE -OPTli <br /> Z; . Vo <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TRU{ RETULATI(ONNS <br /> FORM A(3'83) • . n Y�n (I,��•�t//� Fgi0033A-R7 <br />