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STATE OF CALIFORNIA t <br /> STATE WATER RESOURCES CONTROL BOARD W�� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A a: <br /> X <br /> COMPLeTE THIS FORM FOR EACH FACILITY/SITE <br /> X <br /> MARK ONLY 1 NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 77 2 INTERIM PERMIT a 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NA E NAME OF R <br /> OPERA <br /> 1�RC-s-k�6e �A-'60Ns � NC . <br /> ADDRESS (� NEAREST CRQSS STREET PARCEL 0(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE 0 WITH AREA CODE <br /> �(3NT�cn CA X15331 402- 12v S <br /> ✓ Box <br /> TO INDICATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION i�, 2 DISTRIBUTOR ✓ IF INDIAN Ix OF TANKS AT SITE E.P.A. I.D.tt(epnmaq <br /> RESERVATION <br /> Ql 3 FARM 1 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE WITH AREA CODE DAYS: AME(LAS�Tt�FIRST) C$��� 2�2, I�3�q <br /> t4 �OT ( S b2� v2-1 LOS ARcp r\\ ,\*JC&ACUn t--JL <br /> I C <br /> NIGHTS: NAME(LAST,FIRST) PHONE t WITH AREA CODE NIGHTS: NAME( T.FIRST) NOo 2Z-1-2- l0 3 a 1 <br /> MGR, oN �v k s�ti 4a2. 12oS �Rw a� ear cL Au 1 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Ng\ c L\A S <br /> MAILING OR STREET ADDRESS ✓ bo:to indrau <br /> INDIVIDUAL �Q LOCAL-AGENCY Q STATE-AGENCY <br /> •O ORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE WITH AREA COD <br /> a'p\ .G C& qd-)oz-1D6-_ 8 ( �y �—)o—Sgc)q <br /> III. TANK OWNER INFORMATION.-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa b ft au <br /> �^ �; INDIVIDUAL Q LOCAL-AGENCY QSTATE-AGENCY <br /> O �Sld3� NI-CORPORATION PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME \ - STATE ZIP CODE PHONE t WITH AREA CODE <br /> CA G 0202- 3B 11 (D�0-S�Oq <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) H01 4 1,-1 Q S (� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b ind"14 1 SELF INSURED 0 2 GUARANTEE 0 3 INSURANCE Q 4 SURETY BOND <br /> 5 LETTER OF CREDIT Q 6 EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Leaal 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: I.= IL F— III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAM (PRINTED 6 SIGNATURE) APPLICANTS TITLE DATENTW AV YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY tt JU ISDICTION tt FACILITY tt <br /> LOCATION CODE OPTIONAL !CENSUS TRACT x -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> I <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 /> FORM A(5-91) FOR0033A 5 <br /> gyp'. 50. JUAc{v". Co . &J'J . \\QF <br /> sli ok'cbt r, C. . gS-Lo\_ O3gg <br />