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C�OVn � <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W��, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A . - a: <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT F7 3 RENEWAL PERMIT F7 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT X 4 AMENDED PERMIT [:] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OP RATOR <br /> ,A2� `i9C/t/TY 7*,9,Z 33 pe-rew .1'4C4q&-//1 v <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 7_GJO4 136A,41 117iAI Wi-r Off jt/,r petit- "rl <br /> CITY NAME STATE I ZIP CODESPH NE 4 WITH AREA CODE CA 957-07 �Zv�� �7�'�5-5-52 <br /> I/ BOX <br /> TOINDICATE rIecORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION F7 2 DISTRIBUTOR Q ✓ IF INDIAN 1#OF TANKS AT SITE I E.P.A. I.D.A(optional) <br /> RESERVATION <br /> Gl 3 FARM � 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PIJONE# ITH AREA CODE DAYS: NAME(LAST,FIRST) .77Z—4j'f'417 <br /> 41'1v1�h/Ay /��Cei ?�9 9Z�'j"'S5'� 4,P-C.v�'IRi.vi�'�/gNrr <br /> WITH AREA mnc <br /> NIGHTS: NAME(LAST,FIRST) RHONE N ITN AREA CODE NIGHTS: NAME(LAST,FIRST) ?'7 Z— 4,3 f9 <br /> M/�ingc'0e ov,a.iY FpQ 4 7t-3Y5-z 4eCO 1'e?1hA1jcN1A-1e <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME ^"v <br /> � ���e�� ✓®� � CAPE OF ADD FOjiMATION <br /> /7 415 <br /> MAILING OR STREET ADDRESS C ✓ box 10 indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Rd eog � � Q<CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE WITH AREA CODE <br /> Aq're3"a G",� qvT®2- 107 j9og' <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME O/_7RwR 19�1`� I Iff rl ^M^ (/ CARE OF ADDRESS INFORMATION <br /> MAILING/O RR'S`T`REEEETADDDRESS ✓v 1C.��� 7� ✓ box tlnd�� Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> P &07A6 ( ,CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY <br /> Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PNx <br /> 7 10 <br /> ITHAREA CODE <br /> %C�1.4 Sp / C <br /> 47/� &j7 0-9t <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ '4_74 -10101 & <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate 5irl SELF-INSURED 2 GUARANTEE 0 3 INSURANCE Q 4 SURETY BOND <br /> LQ 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 11 is checked. <br /> [CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. It. I <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PR TED&SIGNATURE) m APPLICANTS TITLE DATE MONTH/OAYYYEAR <br /> i{�a�11q- kA <br /> LOCAL AGENCY USE ONLY <br /> COUNTY tt JURISDICTION n �FACIILIT�Y# <br /> 1 1 1 1 1 1 1 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT a -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 /> FORM A(5-91) FOR0033A-5 <br />