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STATE OF CALIFORNIA �e 'a moi* <br /> STATE WATER RESOURCES CONTROL BOARD u vim, e o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 'n <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION PERMANENTLY CLOS <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE SO <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR fACILITY NAME NAME Owe <br /> F OPERATOR <br /> c S G <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> '� Sl��mE- u <br /> CITYNAME STATE ZIP CODE SITE PHONE#WI AREA CODE <br /> S-6 CA 2a9 c D33 <br /> ✓ BOX ON'CCRPORATION INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY' STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> #ownwof UST@ a public agency,complete the following name o(swermorol 4Nision,inion or olfm which opemles the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESEIRVATIION #OFTANKS AT SITE .p.A. I.D.#(op6maq <br /> ❑ 3 FARM Q 4 PROCESSOR �/�OTHER OR TRUST LANDS •� /fMV M�C <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) /lam — PHON��WITH AR CO�� 1 DAYS: NAME(LAST,FIRST)/IQJ pHON p7H; CpDE <br /> fflNIGHTS: NAME(LAST,FIRST) l/ P O�`O�h'ITH AREA CCQDE U�/'l, NIGHHTTS: NAMEV(LASW)// <br /> T,VF1IRST) 9PHONE#WITHAREACOJ_DE <br /> �/7A-] VG <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COIIAPLFTFD) <br /> NAME�� CARE OF ADDRES INFORMATION , ;\ — <br /> Ljhl <br /> MAILINGOR STREET ADDRESS ✓ tci to hoiYa O INDIVIDUAL 0 LOCAL-AGENCY lY 0 STATE AGENCY <br /> "J(p /N �Ip 'CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITYNAM ^ STAjC� ZIPCODE <br /> I� P��#WITH AREA CI, � <br /> OD <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) l/}-F' tzLCIY <br /> NAME WNERARE OF ADDRESS INFORMATION <br /> CIC j ?DA r> cu <br /> M/AIL—ING OR STREET ADDRESS ^_nA�p� 'l ✓ Mo Iomcata 0 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> �J L 1 A -'*p 5_Yyl� looCOTIPORATION O PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITU NAA 4i*C PV STATE} ZIP COCA � �2� P2N0 '�/oq N WITH AREACODE <br /> 0.;k220 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(9166))322-9669 if questions arise. <br /> TY(TK) HO M44- -� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to MateSELF-INSURED O 2 GUARANTEE 0 S INSURANCE O 4 SURETYBOND O 5 LETTER OF CREDIT Q 6 EXEMPTION 0 T STATEFUND <br /> O&STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O99 OTHEP <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.❑ III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTYOF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OW ER'S NAME(PRIN ED&SIGNATURE) TANK OWNER'S TITLE DATE VOVWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY ly <br /> mI Q 13 1 18 !a <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> y Gr] <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 /> Awl <br /> FORMA(6-96) OWNER MUST FILE THIS FORT THE LOCAL AGENCY IMPLEMENTING THE UNDEFIGRD#TOFIAGE TANK REGULATIONS <br />