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/* o(� <br /> vt4� <br /> STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD�� -�(p'G) UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 5 ❑ <br /> CHANGE OF INFORMATION 7 PERMANENTLY CL <br /> MARK ONLY El ❑NEW PERMIT 3 RENEWAL PERMIT <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> ILITY/SITE INFORMATION&ADDRESS- MUST BE COMPLETED <br /> 1. FAC ( ) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> _14Er 9a 840 00*4 a � o INC. <br /> ADDRESS NEAREST CROSS TREET PARCEL#(OPTIONAL) <br /> L4400 W*TML.ov R o 1Ijew <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> STOG1C104 CA 9 5Z.1 S�; 7.oq-4q 31--218 <br /> ✓BOX DE CORPORATION INDIVIDUAL I]PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 9 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 1 GAS STATION Q 2 DISTRIBUTOR = RESERVATION F INDIAN #OF TANS AT SITE E.P.A. I.D.#(optional) <br /> Q 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> - EMERGENCY CONTACT PERSON(PRIMARY) ` EMERGENCY CON =option <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> e,1451reo tj k)* �q-g31-2196 eA&am Wi0W0n 1 goo-42.3-3529 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 2oq-1Sf o�?31-p4 <br /> OPER WNER INFORMATION- <br /> NAME CARE OF ADDRESS INFORMATION <br /> C1 rs <br /> MAILING OR STREET ADDRESS ✓ box to fdcate Q INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> T,0.7D CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> CW— ggs83-O qo q <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARVF ADDRESS INFOR ATION <br /> H 1257PSV T <br /> MAKING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> PCORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> .Z G� Vss-3--o901510-9147--ITODI-Im- <br /> IV. <br /> BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4_14- - 0 3 1 61 1 3 <br /> V. PETROLEUM UST FPNA C A RESPO SIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate _ISELF-INSURED =2 GUARANTEE =3 INSURANCE Q 4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION =7 STATE FUND <br /> D 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O 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: 1.❑ II.❑ 111.E — <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE M NTH/DAY/YEAR <br /> rA0A4<Vro "SLs'rPt+4T <br /> LOCAL AGENCY USE ONLY L, <br /> COUNTY# JURISDICTION# FACILITY# <br /> FTTI V3 - . <br /> LOCATION CODE -O Tl0NAL CENSUS TRACT#-OPT/ NAL SUPVISOR-DISTRICT CODE -OP / NAL <br /> i <br /> THIS FORM MOST BE ACCOMPANIED BY AT L (1)OR MORE PERMIT APPLICATION- FORM B,UNLESSJM IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6-95) <br /> OWNER MUST FILE THIS FORM 10THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUIWORAGE TANK R,E�QUILATIIIOn�NS <br /> /� �� <br /> 0 <br /> � �y`�� ✓ <br />