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FV <br /> ,OUR eS�. <br /> STATE OF CALIFORNIA �? <br /> 9 <br /> STATE WATER RESOURCES CONTROL BOARD w , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a �D <br /> COMPLETE THIS FORM FOR EACH ILITY/SITE <br /> [- <br /> MARK ONLY 1 NEW PERMIT F—] 3 RENEWAL PERMIT [Zr5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Ej 2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> 44 �G�- C U� -ozo �/ 2 <br /> ADDRESS NEAREST CROSS TREET <br /> `7/ OR`s LvJ'—o <br /> CITY NAME STATE ZIP CODESITE PHONE#WIT AREA CODE <br /> ADZ- ca �� a )33� — S2 <br /> ✓ BOX CORPORATION INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> TO INDICATE DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR0 RESEIF INDIAN RVATION #OF TANKS AT SITE I E.P.A. I.D.#(optional) <br /> 3 FARM 0 4 PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE AYS: NAME(LAST,FIRST) w L <br /> /L 4W!� f.�E L �_)PV 415) —777 GPHONE a WITH AREA r0nF <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box toind' to INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> �0 ��� ~� CORPORATION (] PARTNERSHIP COUNTY-AGENCY (� FEDERAL-AGENCY <br /> CITY NAME STATE ZIP�O�� qN/ i(W2-3AREA C9 l' <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) l7 l <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> :rc_ <br /> Ineze-l_- <br /> MAILINP OR STREET ADDRESS ✓ box to indicate = INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 46 VAIJ I 2—f N CORPORATION = PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME 6TATEA ZIP CODE!23_7_'6z__ <br /> �� HONE#WITH A�A COD; <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - 01011 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate O 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 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: 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(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 1W I 1 103 12— <br /> LOCATION <br /> ZLOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL // <br /> UZ/ <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 />