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s _ <br /> . a <br /> STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD� UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITIE <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOS <br /> ONE REM 0 2 INTERIM PERMIT I AMENDED PERMIT a TEMPORARY SITE CLOSURE 31 / <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAMEpOOPPER TOR <br /> A REBS a 11 <br /> NEAREST CROiSS STREET PARCEL I(OPTIkUU <br /> 10 )40-el <br /> CITY NAMSTATE JC' DE SITE PHONE i WITH AREA OODE <br /> K CA <br /> I/ Box <br /> TO INDICATE CORPORATION 0 INDIVIDUAL Id.PARTNERSHIP Q LOCALAGENCY �GOUNTY#OENCV' �STATE.AGENCY- 0 FEOEML-AGENCY' <br /> X owner d UST b a public en g \rJe <br /> agency.aonplele the IOSawln :named Supe or of dMbbn,section.or duce which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN a OF U TANKS AT SITE E.P.A. I.D.i p000nall <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAV AME MST,FIRST) PHONE a WITH AREA CODE DAYS: E(LAST,FIRS PH NE a WITH AREA CODE <br /> 7RMI� a- a 0k4 , 4+b <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNEP INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS FORMATION <br /> MAILING OR STREET ADDRESS ✓bu[bbdbaN INDIVIDUAL 0 LOCALdGENCY 0 STATE AGENCY <br /> O CORPORATION 0 NRTNERSHP 0 COUNTYAGENCY O FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATIO (MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bulondeMe INDIVIDUAL 0 ALAGENCY 0STATE.AGENCY <br /> _ 0 CORPORATION O PARTNERSHIP 0 CO N <br /> AGENCY 0 FEDEMLAGENCY <br /> CITY NAME STATE ZIP CODE PHONEX7 AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [4-T4--]- OOO ax""� B.o.E•rx <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓b„bMbW I SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 1 SURETY BOND <br /> 5 LETTER OF CREDIT O 6 EXEMPTION O IS OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I orrr111 its checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II.17(1 It.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S <br /> OWNER'S NAME(PRINTED B SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY Rea S D 4�a't Z� <br /> COUNNTTYT'I'x JURISDICTION• FACILITY• <br /> m t---IJ.SS1 <br /> 11 <br /> LOCATION CODE -OPTIONAL CENSUS T7A -OPTIONAL SUPVISCNI DISTRICT CODE -OPTxWU <br /> o a3 ' (61o ©o <br /> TNIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTINGREGULATIONS THE UNDERGROUND STORAGE TANK REGULATI <br /> FORM A(3N3) FOROlOMAT <br />