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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD iy +c oM1 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED.SITE l <br /> ONE ITEM ❑ 2 INTERIM PERMIT Q 4 AMENDED PERMIT E] B TEMPORARY SITE CLOSURE t <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NA F OPERATOR <br /> ADQRESS\ Ill� NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME/ I STATE <br /> CA ZIP CC-T3 $I O���p a, 3 <br /> ✓BOX O CORPORATION INDIVIDUAL F—) PARTNERSHIPO LOCAL-AGENCY a COUNTY-AGENCY' O STATE-AGENCY' FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 'No.9rof UST@eDublE age plate Nefolbwng:naive of sopemord&is,on,section or olfiMwhicti operates Me UST <br /> TYPE OF BUSINESS 7 GAS STATION O 2 DISTRIBUTORO RESERVATION <br /> ✓IF INDIAN qOF TANKS AT SITE E.P.A. I.D.N(optronal) <br /> 0 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> D $: NAME(LAST,FIRST) PHONE#WITH AREA C DE DAYS: NAME(LAST,FIRST) PHONE#WITH AflEA CODE <br /> L 2�- - 003 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> V <br /> MAILING OR STREET ADDRESS ✓ bDXbh&W4 = INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> 4,0 �Jckaff— �&SgJAjrp, CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CI AME $T9TsF� ZIP CODE ` PHONE p NTH AREA CODE <br /> tylAst— <br /> �A ,,`j 2 �a3 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> N OF OWN CARE OF ADDRESS INFORMATION <br /> MAILING OR STRrEE�T ADDRE$s ✓ boxtoinoimle Q INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> �r Y! CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> TY NAME <br /> STATER <br /> DE 3 b PHkWI823- <br /> T-HA'REAC-E n,K� <br /> 04 , <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBE` -- <br /> NUMBER e; <br /> (916)322-9669 if questions arise.L/ 6 `3 !(CJ <br /> TY(TK) HQ 4 [4--]-J <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bFx10 W ale O I SELF-INSURED O 2 GUARANTEE =31NSURANCE 0 4 SURETY BOND O s LETTER OF CRm1T O N EXEMPTION =T STATE FUND <br /> � 8STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O99 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: I.❑ II.O III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNAT TANK OWNER'STITLE DATE MONTHIDAYNEAR <br /> CC_ <br /> � <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY#119(0 <br /> mI a3 I14 <br /> LOCATION CODE -OPTIONAL CENSUS TRACTq -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> / <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SrffINFORIVIATION ONLY. <br /> FORMA(6-95) OWNER MUST FILE THIS FO*H THE LOCAL AGENCY IMPLEMENTING THE UNDERGR0 STORAGE TANK REGULATIONS <br />