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ow <br /> I// STATE OFCAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD s ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F—] 1 NEW PERMIT F�] 3 RENEWAL PERMIT F7 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE REM F-1 2 INTERIM PERMIT L_�] 4 AMENDED PERMIT F_� 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME` , NAME OF OPERATOR <br /> X7 &/ <br /> ADDRESS' IY3a- NEAREST CROSS STREET 4 PARCEL#(OPTIONAL) <br /> CITY NA M STATE ZIP COD 5,z PHONE#W AREA CODE <br /> Y J3 /lfJ�� <br /> TO✓ ox CORPORATION INDIVIDUAL PARTNERSHIP AL-AGENCY <br /> INDICATE O <br /> DISTRICTS' Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <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 0 1 GAS STATION 0 2 DISTRIBUTOR RE/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(oplional) <br /> Q ATON <br /> 3 FARM Q 4 PROCESSOR Q NDS 5 OTHER OR TRUST LA ' C09/'006613 e l <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) / PHO E#WITH AREA CODE <br /> gr <br /> NIS, TS: AME(LAST,`FIR �Q C HONE LI WITHA�CODE NIGHTS: AME(LAST,FIR �H E#WITH AREA CODE <br /> !! GV /l �7 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> f P SG/7 <br /> MAILING OR„,S„T.REET ADDRESS ✓ box to indicate Q INDIVIDUALOCAL-AGENCY Q STATE-AGENCY <br /> io Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME/ �-- ST ZIP CODE PHONE#WITH AREA CODE <br /> 1�.- �J'9 �>S 2 53— <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAIL NG OR STREET ADDRESS ✓ box btndicate Q INDIVIDUAL ]-LOCAL-AGENCY STATE-AGENCY <br /> _ , <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY QFEDERAL-AGENCY <br /> CITYYNAM / STA ZIP CODE PHONE#WITH AREA CODE <br /> .GL SZO L D6 <br /> IV.BOA OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY �) HQ4 F4 - ' <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box IDindicate E-1 1 SELF-INSURED (]2 GUARANTEE Q 3 INSURANCE 0 4 SURETY BOND <br /> L7— 5 LETTER OF CREDIT Q 6 EXEMPTION Q 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: >L It.a 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 8 SIGNED) (. OWNER'S TITLE DATE MONTH/DAYNEAR <br /> tU [� rcTr IrY° <br /> � ° <br /> LOCAL AGENCY USE ONLY T_-D 3 l <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 FORD W-TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO,!mn STORAGE TANK REGULATIONS <br /> FORM A(3193) FOR0033A-i7 <br />