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6OUR <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A a "e <br /> •CSI IFOR N�. <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F—] 1 NEW PERMIT F73 RENEWAL PERMIT F_� 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT MI 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME, # NAME,�F OPERATOR <br /> Urbco+ �ae,t1 5417 atn�es �1 �arfi1-t <br /> ADDRESS , NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 17� E- '`1�e 5&� Alm fie- -1,.1 <br /> CITY NAME ^ aSTATE' ZIP CODE SITE PHONE#WITH AREA CODEI/ BOX <br /> H CA <br /> TO INDICATE IS CORPORATION E::] INDIVIDUAL Q PARTNERSHIP E:1 LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ® 1 GAS STATION 2 DISTRIBUTOR a ,/ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D. (optional) <br /> RESERVATION I <br /> 6.�ia� l U���JSGTV <br /> 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> 1 2- <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> �9 V+ v6 ��((o �� _7 <br /> NIGHTS: NAME(LAST,FIRST) PH NE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 558-7(�07 PHONE#WITH AREA CODF <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NA CARE OF ADDRESS INFORMATION <br /> b►'1 <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 0_ 2-004^ �(QCORPORATION Q PARTNERSHIP COUNTY-AGENCY p0 FEDERAL-AGENCY <br /> CITY <br /> CODE _Z <br /> phc?eVlg X SHT TATE ZI�Z ' 2004" �6Z, 553P CODE PHONE WITH AREA—761 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> � or��'lion <br /> MAILING OR STREET ADDRESS ff1� ✓ box ID Indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 60, 'X+ V8 CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL AGENCY <br /> CITY, ^E STATE ZIP CODE PHONE 0 WITH AREA CODE <br /> r nc ie l X A-? 0 2-208 (ct6)s5e -7(4, <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HOF 4 - �} <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 2 GUARANTEE (] 3 INSURANCE 0 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 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.[�] it.[:�] III.120 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> LICANT'S N ME(PRIf1TED&SIGNATURE) v _ APPLICANTS TITLE �j�`� DATE MONTWDAYIYEEAAR <br /> t"ta 141— L2 ►nom cariG�Ltl -f� Kze-o <br /> lr <br /> LOCAL AGENCY U E ONLY <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 /> FORM A(5.91) FOR0033A-5 <br />