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6,,OUR <br /> STATEOFCAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W nor ae'a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A `:� i., os <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `•�.o��'' ,P , <br /> MARK ONLY t NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SIT <br /> ONE ITEM F-1 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY N ENAME OF OPERATOR <br /> t� r c <br /> ADDRESS NEAREST CRO STREET PARCEL N(OPTIONAL) <br /> 19 ;k,: 3W <br /> CITY NAM STA E ZIP CODE SITE PHONE WITH AREA CODE <br /> S d CA am q-n-g60 <br /> ✓ BOX <br /> TO INDICATE O CORPORATION INDIVIDUAL Q PARTNERSHIP LOCAL-AGENCY OCOUNTY-AGENCY' ��A •AGENCY' � FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner ol UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS O t GAS STATION E�j 2 DISTRIBUTOR ✓ IF INDIAN 8 OF TANKS AT S TE E.P.A. I.D.8(optional) <br /> RESERVATION –_3 FARM O 4 PROCESSOR 5 OTHER ORTRUSTLANDS O <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAM (LAST,FIRS PHONE X WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> A 209 q51-q669 <br /> NIGH S: AM AST, IRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS I FORMATION <br /> o P �t r <br /> MAILING OR STREET ADDRESS ✓ box b Indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> ElFlf�'Ll1 0 CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STgJE, ZIP CODEPHOONE M WITH AREA CODE <br /> SO <br /> `L' <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNE11 6fi <br /> CARE OFA DRES INFO MATION <br /> f <br /> MAILING OR STREET ADDRESS I ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> mqCORPORATION O PARTNERSHIP Q COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NA E STATi ZIP CODE PHONE a WITH AREA CODE <br /> o D q :,3_q669 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - a <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT O 6 EXEMPTION 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: I.=] 11.0 III.,X <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 8 SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> NrmLes Leo s / z. �4�-ice , OZ-30 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY aY JURISDICTION a< QV�V FACILITY <br /> � 1 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL 7UPVISOR-DISTRICT CODE -OPTIONAL <br /> 1 <br /> THIS FORM MUST BE ACCOMPANIED BY AT 1 '(1)OR MORE PERMIT APPLICATION• FORM B,UNLEF AIS IS A CHANGE OF SITE INFORMATION ONLY <br /> OWNER MUST FILE THIS FORk. H THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO. STORAGE TANK REGULATIONS /—&" r J <br /> FORM A(3/93) FORDZM R7 <br />