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STATE OF CALIFORNIA <br />WATER RESOURCES CONTROL SOARO <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />� �� COMPL= E THIS FORM FOR EACH FACIL(TY,5rTE �� vl <br />.NARK ONLY L_ %-R^ PERMIT �! 3 PEAEWAL RERMIT 5 CHANGE OF ;INFORMATION 'I_ T PERMANENTLY CLOSE <br />CNE ITEM �2 NTERIM PEPMIT A .WENDED PEaMIT 8 TEMPORARY SME CLOSURE 'a <br />• NIA l lvvl D NUU NqJ - (PAUJ I Ot UUIVIPLETCD) <br />CoA; A;AC:U1. <br />NAME <br />/� SOF OPERATOR <br />MAILING CR STREET ADDRESS <br />aCCREaS <br />20 <br />` Sr CRCi85TREET <br />PARCEL yCPTICNAQ <br />C:T/ NA`SE <br />C:tt NAME <br />ru nnAnnn <br />—t -STATE–" I ZIP CCCE <br />SITE PHONE A W ITH AREA CODE i <br />ca <br />/ ,9 ,3 <br />x <br />'O INOCATE <br />,�'; CORPCRAT.CN <br />Q :NOIwOUAL Q PMMNE'NSHP L_ LOCAL.AGENCY Q COUNTy.AGE.WC <br />STATE AGE.NCT C FFOEPALAGENCY <br />OGTRCTS <br />TYPE CF 3LSINESS J I GAS STATION <br />2 OISTR13U7CR <br />F INDIAN <br />C F TANAS AT SITE <br />A. <br />P. <br />E. PA. L DA WwAI <br />i� ]FARM <br />` A PRCC'c SSCP ! S OTHER <br />RE <br />pq TRUST LANDS <br />UST ANDS <br />/ <br />EMERGENCY CONTACT PFdSnM IPRIMARVT <br />-- -'---- • EmQRNlQ"VT CONI AUI rLNpUN (]tUUNUAHT)• optlWal <br />,^,ATS: NAME (LAST, FIRST) PHONE A WITH AREA CODE DAYS: NAME(LA.ST.FIAST) <br />NIGiI TS: NAME {LAST, FIRST( PHONE A WITH AREA CODE NC44TS: NAME (LAST. FIRST) <br />Pur c A • vac r-•ne <br />II. PROPERTY OWNER INFORMATION • MUST BE COMPLETED) <br />NAME I WE OF ADDRESS INFORMATION <br />MA:UNG OR STREET ADDRESS Q INONCWLCOCALAGNCY STATE - <br />AGENCY <br />Q mRPOION <br />Q PAATK-7310 `; COUNTYAGE'ACYS <br />Q : ERA4AG"clCY <br />CII NAME STA,e I ZIP CODE i PHONE+WITH AREA CODE <br />!it. INNNWWNteS INrUHNIAIIUN•(MU5T8ECOMPLETED) <br />!LAME OF OWNER <br />CAAE OF ADDRESS INFORAULTICN <br />FACtrTY e <br />MAILING CR STREET ADDRESS <br />yP M Q ItmVCtlAI <br />Q LCGl4AGENCT Q STAIE-AGENCY <br />LOCATIONCA�/�.`.E, -OpW M. <br />Q CORPORATION Q PARTNERSHIP <br />Q CDUNTY.LGENCY Q FEDEPALAGENCT <br />C:tt NAME <br />ru nnAnnn <br />I STATE I ZIP CODE <br />PHONE P WITH AREA CODE <br />•••---•• �nnvl. Mil alv�nwL�Ac rc,c /A+vvvuNl NumtAtm-Ua11(ulb) 3Z3 -95551I questions arise. <br />TY (TK) HO 4 4-( I I I I I I N 0 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED)—IDENTIFY THE METHOO(S) ED <br />./ bl PYefuY L I SEELFANSIIRED Q 2 GUARANTE"c <br />Q 2 NSU Q A SXTETY 20NO <br />Q S :FTTER CFCREdT r—.1 DIEVPiION 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 checked. <br />CHECX ONE SOX INDICATING WHC.H AaOVE ADDRESS SHOULD BE USED FOR LEGAL NOTFICATlONS AND BR.LNG: L = x. El Ill. <br />THIS FORM HAS BEEN COMPLETED UNOEA PENALTY OF PERJURY. AND TO THE BEST OF A(Y KNOWLEOCE. IS TRUE AND CORRECT <br />,PPLCANTS NAME(PRW TED A SIGNATURE) APPLICANTS TITLEDAIC MCNTWOAYNEAR <br />COUNTY o <br />JURISDICTION It <br />FACtrTY e <br />LOCATIONCA�/�.`.E, -OpW M. <br />CENSUS TRAC,T}y/�. OPWNAL <br />SUPVISOR• DISTRICT CODE. OPTX)NAL <br />/ <br />THIS FCRM )RUST SE ACCOMPANIED SY AT LEAST (T) OR MORE PERMIT APPLICATION • FORM B. UNLESS THIS IS A CHANGE nF srrF IMFnRMArnN nut v <br />Pnau a en„ <br />FCP40=3 $ <br />