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1 <br /> Ftb ^ f <br /> VV(� STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A oge <br /> C" COMPLETE THIS FORM FOR EACH F ILRY/SITE tpopt <br /> MARK ONLY W1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [:] 7 PERMANENTLY <br /> ONE REM Q 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE rl <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA FACILITY NAME sro N OF OPERATOR i /r <br /> `.. E I RL <br /> � �� I ` �C 1'�STREET�� PARCEL N(OPfIONAL) <br /> CITY NAME STATE •� ZIP CODE SITE PHONE*WITH AREA CODE <br /> TPt G CA 9576 <br /> TO DCATE CORPORATION INDIVIDUAL [::]PARTNERSHIP Q LOCAL-AGENCY 0 COUNTY-AGENCYSTATE-AGENCY' FEDERAL-AGENCY' <br /> DISTRICTS' <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 M 1 GAS STATION E::] 2 DISTRIBUTORO ✓ IF INDIAN J#OF TANKS AT SITE E.P.A. I.D.X(optional) <br /> IF <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> D YS: AME(LAST,FIRSTI <br /> c PHONE a WITH AREA CODE -� DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> YV <br /> G : (LHT NAME ST,FI T) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> I! mks - a- aq <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> CARE OF ADDRESS INFORMATION <br /> Ka Y-yisl i L(� <br /> MAILING OR STREET ADDRESS ✓ box ioindicate INDIVIDUAL LOCM-AGENCY = STATE-AGENCY <br /> 31T ( ' `� �� �, Q CORPORATION = PARTNERSHIP = COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NA f ST TE , ZIP DE ZZ <br /> PHONE X WITH AADS <br /> Poo <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) /L"�� Q�J <br /> NA OF OWNERCARE OF ADDRESS INFORMATION <br /> Yx1 S 1 R L A <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> i o S T &I Tt --,7 V I (]CORPORATION PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME . <br /> � �� SjL1T� ZIP DE �� PHONE#W AREA CODE <br /> Tylprcl� <br /> L 9641 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bindicate 1 SELF-INSURED =2 GUARANTEE 0 3 I SURANCE =4 SURETY BOND <br /> 5 LETTEROFCREDIT =6 EXEMPTION OTHER W <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is c cked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. 1L III.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT -- <br /> ER'S NAME(PRI D&SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR <br /> S LI <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY <br /> [�# 1 -41-2,19 1,0101 /1 .1 <br /> LOCATION CODE -OPTION L CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT CODE-OPY70AM j <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORMS,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. / <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGUIONS <br /> LAT <br /> FORM A(3193) FOROM34M J <br />