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eW^ t <br /> STATE OFCALIPoRNIA ^�" w <br /> STATE WATER RESOURCES CONTROL BOARD ¢ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A `n� ': <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE `n' �,x�-oa,,,. <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SIT <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSUR <br /> 53 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> ODA OR FACILITY NAME NAME FOPERATOR <br /> ADDRESS / NE ORO STREET PARCEL 9(OPTIONAL) /I �� <br /> 6 V C <br /> CITY NAME STATE ZIP a fj <br /> �, SITE PHONE,WITH AREA CODE <br /> CA <br /> TO Box <br /> RTE CORPOR TI INDIVIDUAL =PARTNERSHIP CAL-AGENCY W <br /> O CMY-AGENCY' STATE-AGENCY' 0 FFEDEMLAGEWY' <br /> If wmer of UST Is a public agency.complete the follewlrg:name of Supemaor of division.sDISTRICTS <br /> office which operates the UST <br /> TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN a OF TANKS AT SITE <br /> �/3 FARM = 4 PROCESSOR 6 OTHER O RESERVATION /�/Jn <br /> ❑ OR TRUST LANDS / ✓rj�Dd <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NA LAST,FIRS1f ������/// PHONE a WITH AREA CODE DAY : NAME(LAST,FIRST) <br /> O 4, ///aJ� _ 9P <br /> IM <br /> WIT (A//ggEvA7CODE <br /> NIGHTS' AMEIyA�T,FIBS- , PHONEa WITH AgEA CODE ^ NIG NA E(LAST,FIRST) OtD PHpryEapgEA SDE <br /> -Cirri ��f- �0 I mit �l `�(` arj <br /> II. PROPERTY OWNER INFORMATION. MUST BE COMPLETED <br /> NAME„_ r CARE OF ADDRESS INFORMATION <br /> ��/L �Ill <br /> MA ING RSTREET ADD S box birdkme <br /> NDIVNXIAL I LOCAL-AGENCY O STATE-AGENCY <br /> CITY NAME �^ L J I�CORPORATISTATE OP COO PARTNERSHIP ED COUNTY-AGENCY 0 FEDERALAGENCY <br /> l/�C PHONE a WITH AREA CODE <br /> vv 9S-320 <br /> III. TANK OWNER IN ORMATION-(MUST BE COMPLETED) <br /> NAME O WNER CARE OF ADDRESS INFORMATION <br /> �l <br /> MAILING ORST qIfiUUHESS ✓box blMkaM INDIVIDUAL <br /> /)J� D LOCAUAGENCV O STATE-AGENCY <br /> CITY NAME - ' CORPORATION D PARTNERSHIP = COUNTY-AGENCY O FEDERALAGENCY <br /> STT TE ZIP ODE PHONEa WITH AREAC DE <br /> c j7 s-Cal <br /> IV.BOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓box bindk9e E-1 I SELF INSURED l 2 GUARANTEE 0 3 INSURANCE <br /> O 5 LETTEROFCREDIT 1-16 EXEMPrION O A SUREr BONG <br /> O 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.1::1 II.D III. <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&SIGNED) OWNER'S HI LE <br /> DATE MONTWDAYrYEAR <br /> LOCAL AGENCY USE ONLY aa <br /> COUNTY a JURISDICTION a FACILITY ti0�t7.6 <br /> m 439. so 8y8 3 <br /> LOCATION CODE -OPTIONAL CENSUS TRACTa -OPTIONAL 9UPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE 011i lNtORWTION ONLY. <br /> FORMA(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORap33AR7 <br />