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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W u <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM As <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY EZ1 NEW PERMIT L_� 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO <br /> ONE ITEM 0 2 INTERIM PERMIT E71 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME # NAME OF OPERATOR <br /> lldec v AM h FAc/,� r lv3/3 5 C�Ic6, <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> MAMTc CA <br /> ✓ BOX <br /> TO INDICATE CORPORATION 0 INDIVIDUAL E�] PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCYSTATE-AGENCY' 0 FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner of UST is a public a ncy,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR [7j 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WIT14i Aj�yiEfr+q DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ARto A-1.4 v T��IA,�rcr /- g� /�/�'wbb,JJ-ff r� <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> �qizcv ,vt/J/,,/ Tt,v4>vOfcI-k:47.-/ zCL,, /- <br /> 11. PROPERTY OWNER INFORMATION MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Iq kC&' Goy 71914")) r "Co E^r v r/ZCJ,"eh/r•1'�, - <br /> S/;A7E <br /> MAILING OR STREET ADDRESSJ C✓ box to indicate = INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> GEN�F/ZI�UinllG UGC, ( /ORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> zA I�ALiY7A G A t7U(o Z 3 /- 7(q- (c%7k_, i/ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> A -!I AiZc,0_/Gr5 e e:�I>�ANS� A�,�G cn�v«�;J.•��..��11� f�E•ac7r/ sRtEni <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY <br /> ���rEQpO/n,/TE v� CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> LA PAZ-MA GA `1n023 (7/4) 6a7C----S4�/ <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HO 14 4- -10 1 0 1015 p lD <br /> V. PETROLEUM UST FINANCIA RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED G' 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT J 6 EXEMPTION L] 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ it. 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&SIGNED L OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> 1 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# a(0 <br /> m1 P51D <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL j <br /> Nz t 17 <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 REGULAnONS <br /> FORM A(3/93) FOR0093A-i7 <br />