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'ou C <br /> r� C <br /> STATE OF CAUFORNIA .` <br /> o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A i., o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °� �o��' 0 ( <br /> MARK ONLY 0 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SIT <br /> ONE ITEM [–] 2 INTERIM PERMIT F-1 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> to o (ko b � r kii <br /> ADDRESS NEA13ESTCROSSSTREET PARCEL 0(OPTIONAL) <br /> bilur Moline whve <br /> CITY NAM STATE' ZIP CODE SITE PHONES WITH AREA CODE <br /> a o id CA 95 -166f <br /> T INDICATE 0 CORPORATION E:l INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' STATE. <br /> AGENCY' Q FEDERALNCV' <br /> If owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST Q A, 1 a N ht <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN Ix OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 0 3 4 PROCESSOR RESERVATION <br /> FARM � [ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRS PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Sz- 06 <br /> NIG S: AM AST, IRSn PHONE i WWIIT[H AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> 11 :26110 <br /> Ii. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE_QF ADDRESS I FORMATION <br /> Aococ)!NOn.-FIA f._.,n 1" <br /> MAILING OR STREET ADDRESS I n ✓ box bIndicate INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 1 0 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY E r L, STrR��7� ZIP CODE 6 PHONE 71 WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) /V, <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> __2 i i IfIA t] bl&A 'a <br /> MAILING OR STREET ADDRESS ` ✓ box bindicate <br /> INDIVIDUAL la LOCAL-AGENCY (] STATE-AGENCY <br /> I (I CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME ST ZIP CODE O PHONES WITH AREA CODE <br /> 16CA31011 6 D/ <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 <br /> F_-1- -7 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate 71 1 SELF-INSURED ]2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> = 5 LETTER OF CREDIT C 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 /> F <br /> ECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. if. 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) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> FTI ail 0i�j <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT 1 T(1)OR MORE PERMIT APPLICATION- FORM B,UNLE' IIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FOR,. H THE LOCAL AGENCY IMPLEMENTING THE 0%. _STORAGE TANK REGULATIONS I ' !o" �I 7,4 <br /> FORM A(3/93) (rp oG✓� /y FataaM-W <br />