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a � <br /> • • r <br /> t"UR <br /> •' aur C <br /> STATE OFCAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY Nt NEW PERMIT F73 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SI <br /> ONE REM F-12 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 0 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> IF DRA OR FACILITY NAME NAME OF OPERATOR <br /> 05 AS t A�Mt poofd Y. D' AW -,,,SWARAtJ eH&JHAV <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> o! �", �HA2T�"2 414 Y sr A10V.sc ares <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> mS'TOGKi o. ca �j5 2©�v (toll) yl07-o3©5 <br /> BOX <br /> TO INDICATE D CORPORATION 0 INDIVIDUAL V PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCYSTATE-AGENCY' Q FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS Fj?l t GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN IN OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS „3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) r, / P�+ONE#WITH AREA CODE <br /> 0rg1KAAJKyr ©oA) (2-,%) 9- 2 -�� '� sm14,eAA1 c�vI)j4W,✓ "5l <br /> NIGHTS: NAME(LAST,FIRST) PHONE# NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Cj <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> A" L Crud/ , ` PA <br /> MAILING OR STREET ADDRESS box to indicate E:] INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> GSL CORPORATION E/PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> i CITY NAME' t STATE ZIP CODE PHONE#WITH AREA CODE <br /> gs708F 4164- o3 c)5 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER ���� >�?o u,DL� /{P6 CARE OF ADDRESS INFORMATION <br /> i <br /> MAILING OR STREET ADDRESS / ✓ box b indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 70/_4_' E'�/Q.el4 2_ _! � 0 CORPORATION EePARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CIN NAME'�1�—��/ �� � t)2 STAB A ZIP CODE © - PHONE#WITH AREA CODE � <br /> r �+ l a3 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [4-74- - D 3 IJP 1�o 1#f I 8 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY'(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box toindicate t SELF-INSURED 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 6 EXEMPTION 0 99 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: 1.0 it.= 111.0 <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&SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR <br /> K14ALyoo,V r. 0;ri1VAA1 c-.9mX04i-P4_OrA16L <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# I ` <br /> LOCATION CODE -OPTIONAL <br /> CENSUS <br /> ACT# -OPTIC SU <br /> L PVISOR-QjSTBJCT COP;OP77ONAL <br /> n �lU <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 /> FORMA(3/93) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIM +�0 3t <br />