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STATE OF CALIFORNIA • <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A ' <br /> t <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT <br /> ONE REM ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY <br /> CLOSED SITE <br /> FTO <br /> ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT <br /> ❑ 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMP <br /> DBA OR FACILITY NAME LETED) <br /> L NAME OF OPERATOR <br /> [ADDRESS <br /> NEAREST CROSS STREET PARCELN(OPrK1NAU <br /> NAME <br /> Gott STATE ZIP C/ODE SITE PHONE WITH AREA CODE <br /> ✓ Box CA �j off <br /> O INDICATE �CORPORATION INDIVIDUAL (]PARTNERSHIP � LOCAL-AGENCYer d UST Is a Public agencymrtlele thfof Supervisor of tlNlsbn,seetbn,DIS RIIC�whkh 0 COUNTY#GENCV' O STATE AGENCY' FEDERALAGENCY' <br /> OF BUSINESS aperales the UST <br /> 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#mp,=a/I <br /> 3 FARM ❑ / PROCESSOR ❑ 5 OTHER OOq RESERVATION <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> Daus: Na E sr,Flgsr) EMERGENCY CONTACT PERSON (SECONDARY)-oPtlonal <br /> S PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> L� `n� A59 —,V l C PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COE <br /> NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME <br /> Ls� CARE OF ADDRESS INFORMATION <br /> MAILING 7OR STREET ADDRESS <br /> ✓Wxkc qls Q INDIVIDUAL E:] LOCAL AGENCY EJ STATE-AGENCY <br /> CITY NAME •„—� O CORPORATION = PARTNERSHIP I�COUNrY-AGENCY <br /> ZIP CODE —] FEDERAL AGENCY <br /> STATE <br /> P CODE HONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE <br /> NAME OF COMPLETED) <br /> OWNER <br /> G�� sF CARE OF ADDRESS INFOflMATION <br /> MAILING OR STREET ADDRESS <br /> `L� �'E,rT�J` �^ ✓ bor biMicaa INDIVIDUAL LOCpLAGENCY <br /> CITY NAME iJ CORPORATION PARTNERSHIP STATE AGENCY <br /> // COUNTY#GENCY 0 FEDERAL AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916 322-—0,11 uesGonslarise 36�` ,3 <br /> TY(TK) HQ 4 q_ _ <br /> EHV. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> boa=1w­ 0 1 SELF INSURED 0 2 GUARANTEE <br /> EH=1w­ <br /> 0 5 LETTER OF CREDIT Q S EXEMPTION 3 INSUgplICE L_j A SURETVBOND <br /> 9D 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 ❑ II ❑ 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 8 SIGNED) <br /> OWNER'S TITLE <br /> DATE MONTWDAYrYEAq <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION At <br /> FACwrryg 7530 _ <br /> p /^�' <br /> LOCATION CGDE -OPTIONAL CENSUS TRACT* -OPTIONAL '/ t/r1 <br /> .Z3 O SUPVISOR-pIBTgICTFp/W(_. .b 9y <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(393) OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU�STORAGE TANK REGULATKINS^} G J <br /> �r% d-1 1I / '_ <br />