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STATE OFCALIFORWA <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 NEW PERMIT 0 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SIT <br /> ONE REM S INTERIM PERMIT 0 4 AMENDED PERMIT 0 8 TEMPORARY SITE CLOSUR <br /> 53 <br /> I. FACILRYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> OSA OR FACILITY NAME - NAME OFOPERATOR r�IU <br /> ADDRESJ--CJ S _ < / NEA TCRO STREET PARCEL 0(OPT)ONAU <br /> C <br /> c- <br /> CITY NAME STATE IIP COD <br /> SITE PHONE#WITH AREA CODE <br /> r, <br /> CA - <br /> ✓ soz <br /> TOINDICATE Q CORPOR TI Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' <br /> 'II owner d UST Is a public DISTRICTS' IQ FEDERAL <br /> -AGENCY' <br /> p agenry,mrtplela the lollowing:name of Supenkor of dNisbn,sembn,or ollice which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN A OF TANKS AT SITE E.P.A. 1.D.#Topicna# <br /> ® Q/3 FARM Q 4 PROCESSOR 5 OTHER O RESERVATION <br /> OTRUSTLANDS <br /> R <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional Ct' <br /> [NJGHTS�#AME <br /> YS: NA LAST,FIRST) PHONE#WITH AREA CODE DAV NAME(LAST,FIRST) 1 HO�p�?#W�IT�"I A/gE_A7CODE <br /> U C:' ✓�/.PITC I.T �Jtf ��� C _ # (r/ <br /> c�s T,FIRST��,yA� PHONE#WITH AREA CODE NI�Gy/ NA E(LAST,FIRST) PHONE s WITH AREA CODE <br /> Afer /�G // %r, d�J , I LI/ <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING QRSTREETADDRASS ✓ Dor bintlkale <br /> L u �7 A C_ `�I4 / NDIVIOUAL Q 1000.4AGENCY Q STATE-AGENCY <br /> (/, ! jt�'1' CORPORATION Q PARTNERSHIP Q COUNTY AGENCY Q FEDERAL-AGENCY <br /> CITY NAM �/"' S ZIP CODE PHONE#WITH AREA CODE <br /> 111. TANK OWNER IN ORMATION-(MUST BE COMPLETED) <br /> NAME O WNER '� CARE OF ADDRESS INFORMATION <br /> J li <br /> MAILING OR STRE TADORESS ✓hoa biMkNe <br /> -I Q INDIVIDUAL Q LOCAL-AGENCY QSTATE-AGENCY <br /> CITY NAME IQ CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL AGENCY <br /> PHONE#WITH AREA C9DE <br /> IV. BOARD OF EQUALIZATION 6ST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ M44- -L <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ W.bindkale Q I SELF-INSURED =2 GUARANTEE Q 3 INSURANCE Q /SURETY BOND <br /> IQ 5 LETTER OF CREDIT Q 6 EXEMPTION Q 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.O II.O 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(POINTED 8 SIGNED) OWNER'S TITLE <br /> DATE MONTWDAY/YFAq <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILETY#gl Ub <br /> m a3�a � so 8Y8 3 <br /> LOCATION CODE -OP7/ONAL CENSUS TRACT# -OPi/OAIAC SUPVISOR-DISTRICT CODE -OPTIONAL <br /> f0 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE 0 OR T1 NN OILY. <br /> FORM A(3/1113) OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUWORAGE TANK REGULATIONS <br /> FOROOJY <br />