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owoy <br /> STATE OF CALIFORNIA � + •"��+. <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A f oe <br /> y. . <br /> °'1�•un <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ❑ M <br /> ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE c!.-? <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DSA OR FACLITYNAME /J /7 NAME OF OPERATOR, <br /> �I�/ 4 S l C✓/,CJ /i ✓f o f <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITU NAME STATE ZIP CODE S TE PHONE#W ITH AREA CODE <br /> o/J CA 5360 7 S f- z3/ 3 <br /> BOX <br /> TOINDICATE CORPORATION O INDIVIDUAL Q PARTNERSHIP a LOCAL-AGENCY ED COUNTY-AGENCY O STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS T GAS STATION ❑ 2 DISTRIBUTOR o ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(OplimV) <br /> RESERVATION <br /> 0 3 FARM O 4 PROCESSOR = 5 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) <br /> ;// 2ex� S -Z3l3 PHONE*WITH AREA mnp <br /> NIGHTS: NAME(LAST,FI ST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME �9 �/' / CARE OF ADDRESS INFORMATION <br /> CO P G/( 19 � P.fFF/ rC <br /> MAILING OR STREET ADDR S /- ✓ bo#b4tlkab O INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> G (Ie ,,i,Je14 f- 117� ZOO EatCRIPORATON [::] PARTNERSHIP ED COUNTY-AGENCY 0 FEDERAL AGENCY <br /> Citt NAME STATEZIP CODE PHONE#WITH AREA CODE <br /> � <br /> 4 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Ll vlv r/s/� /hc <br /> MAILING OR STREE7ADDR S ✓ box biMkale D INDIVIDUAL <br /> a LOCAL-AGENCYO STATE-AGENCY <br /> _ (,7 CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> jcn ,�aMoil a 55&3 510 8YZ-9r' >5o <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - Z y <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ bor oirAkal# SELF-INSURED Q 2 GUARANTEE 0 3 INSURANCE 4 SURETY HIND <br /> 0 5 LETTER OF CREDT O a EXEMPTION 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 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 11.❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS <br /> ME(PR INTED a S IGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 0/-I,—IV/Q 33 <br /> m 66 <br /> LOCATION CODE •OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> © a3 f0 3z6 o <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 /> FORM A(5-91) FORaOM3�AA.5 <br />