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M S L 'ceuua e. L <br /> STATE OF CALIFORNIA r c': <br /> STATE WATER RESOURCES CONTROL BOARD w��a, ,v m <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ° <br /> o <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ] PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACIU NAME r jNAME OF OPE qTOR C // <br /> M�IterumnP Y�s� �n c1/III <br /> G) /�o.A Cyn hiC1 O/'1Lssarl <br /> ADDRESS Zip A C 'C P`, NAA�,AAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> �H /✓p- �cLh�if{ /ZQaC� fJln2nc, V i S <br /> CINNy�ME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> C1ewlei CA g59� Flo 7- I6'g7 <br /> TOOI/ BOX <br /> INDICATE O CORPORATION Q INDIVIDUAL D PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCYO STATE-AGENCY D FEDERAL AGENCY <br /> DSTRI <br /> TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR / IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> ❑ ESERVATION <br /> 3 FARM 4 PROCESSOR L: OTHER OR TRUST LANDS 1 CA C 001 a 41LA'6`1 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> Ad) 7 <br /> 5C>4 Cbn��L .tiC ID) a8�- Ib� PHouE-WEELLAREACODE - <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAM CAREOFADD INFORMATION <br /> L�. 3 . /1'1 . Lt . <br /> � Lyn IC�x C. Aoll1i5Son <br /> M LING OR ST ET ADDRESS cc ✓ boxbindl ate 0 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP O COUNTYAGENCY FEDERAL <br /> TY NAME STATES ZIP COD PHONE#WITH AREA CODE <br /> 0C;f)<Ic1na{ C///fi `r h3-1055 150.) 98 - to4io <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NA— OXN/Vk EG . •• 1 , ' `\ CABE OF p /LI DRE$SINFORMATION <br /> MAI ING OR STRRE l ADIDDRRESSV ^^ L L ✓C box bindica/lteQ INDIVIDUAL H(]GLOCAL-AGENCY [� STATE-AGENCY <br /> x 0 x (7 X O�I o 5 5 =CORPORATION O/ PARTNERSHIP )bid Sl- <br /> COUNTY-AGENCY <br /> �LO FEDERALAGENCY <br /> C NAME STATE zlpFloh J PHONE <br /> o 1�v <br /> a�k ��n� lam.-//P1 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ L-L I-I 2 -jl 15]K <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ boxtoindicate !J tSELFINSURED 0 2 GUARANTEE 3 INSURANCE L--14 SURETY BOND <br /> L-1 5 LETTEROFCREDIT 6 EXEMPTION W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or11 is <br /> checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ IL,I�yI III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S N E(PRINTEDE IGNATURE) APPLICANT'S TITLE DATE MONTH/DAYNEAR <br /> Syron n-c c�co>'/ C 227,210 51,2119 2 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It FACILITY At <br /> LOCATION CODE -OPTIONAL CENSUSTRACT# OPTIONAL -----[=DISTRICT CODE OPTIONAL `MV ��/e.# <br /> �l <br /> z;. SU (r- 7/ <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(12-9T) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR6033AR6 <br /> r <br />