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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A :. <br /> �( COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY —Vo f NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O7 PERMANENT <br /> ONE REM 2 INTERIM PERMIT 0 A AMENDED PERMIT 8 MPORARV 317E CLOSURE <br /> I. FACILTTY/SITE INFORM ESS-(M BE COMPLETED) <br /> NAME NAME OF OPERATOR <br /> NS & N <br /> NEAREST CROSS STREET PARCEL#(OPTIMAL) <br /> 9 t <br /> CITU NAME STATE ZIP CODE SITE PHONE t WITH AREA CODE <br /> S To T CA42 r <br /> T./ BoATE �fX)RIK)flp7gN (]INDIVIDUAL (]PARTNERSHIP DISTRICTS' <br /> Q COUNTY#GENCY' STATEAGENCY' I�FEDEw1LAGEWY' <br /> DISTRICTS' <br /> •6 owner of UST Is a public agency.cor plste the foloWng:name of Supervisor of dMslon,sec1bn,or of ios which Operates the UST <br /> TYPE OF BUSINESS O T GAS STATION 2 DISTRIBUTOR Q RESERVATION 1#OF TANKS AT SITE E.P.A. I.D.t(pum* 1 <br /> Q 3 FARM 6 PROCESSOR DjQ 5 OTHER OR TRUST LANDS <br /> RSON (PRIMARY) EMERGENCY CONTACT PERSO <br /> DAYS: NAME(LAST.FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE•WITH AREA CODE <br /> TT l-7/u—S9.z —6z9 r .✓ /-9/L-39/-i+-s0 <br /> NIGHTS: NAME(LAST.FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST, <br /> IR T) PHONEi WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION• MUST BE C <br /> NAM CARE OF ADDRESS INFORMATION <br /> E uS T /tS�N Co. �. P <br /> MAILING OR STREET ADDRESS -/box bBMkms D INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> P CORPORATION O PARTNERSHIP COUNTY AGENCY (� FEDERAL-AGENCY <br /> CITY NAME STA ZIP CODE PHONE i WITH AREA CODE <br /> E ss /968 s-( 7iu -S�e GL > <br /> NAME OF OWNER ,p CARE OF ADDRESS INFORMATION <br /> M ILIN ORSTREETADDRESS ✓ box bBMicW f� INDIVIDUAL O LOCAL-AGENCY f�STATE-AGENCY <br /> t o 6CORPORATION [L) PARTNERSHIP EDCOUNTY-AGENCY FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE 0 WITH AREA CODE <br /> /¢ /9 60 3-0 5 6 3 <br /> IV.BOARD OFEOUAL NT NUMBER•Cali 916)322.9669 it questions arise. <br /> TY(TK) HO 4 4- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ box to Micas W1 SELF-INSURED 0 2 GUARANTEE ED 3 INSURANCE Q<SURETY BOND <br /> =5 LETTEROFCREOIT O 6 EXEMPTION Q W 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 chocked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.= II.�Q 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNE R'S NAME(PRINTED 6 S IGNED) „L. T OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY 3 It <br /> rm0 JURISDICTION• FACILITYIv \\ <br /> LOCATION CODE -OPTIONAL CENSUS TRACTO -OPTIONAL SUPVISOR-ppW��S,,T((R''��IC,,Trr�CODE -OVRpNAL <br /> 3 VIJCJ <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3103) / __-3(A3A{(T <br /> �CAEWN 01E f�—vv,�,�al( � l�GS7 a7 i�� <br />