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0 ,F`77 <br /> `6�,�•�dt C <br /> STATE OF CALIFORMA f4 r <br /> STATE WATER RESOURCES CONTROL BOARD VR R 2 0 1995 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ENVIRONMENTAL HEALTH <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 7 PER <br /> ONE REM 2 INTERIM PERMIT 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> L <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> � <br /> CITY NAME STATE TZ41;F36E SITE PHONE X WITH AREA CODE <br /> CA <br /> ✓ Box <br /> TO INDICATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q 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 Q t GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.'s(optional) <br /> 0 3 FARM 0 4 PROCESSOR 5 OTHER O RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> F-KBV L <—_6 [ 0, !1V'A rA�k� <br /> NIGHTS: NA LAST,FIRST) PHONE#WITH AREA COD NIGHTS:NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 2 <br /> ,,W1, <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> �'AG 1~lG 150L)L_ INl , . MIG V <br /> MAILING OR STREET ADDRESS ✓ x bkMiaate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> C4&&41 N6 EL5r&7 tKOORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY-NAME. STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION.(MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> INtt ST T ✓ Wxtoindicate Q INDIVIDUAL Q LOCAL-AGENCY [__1STATE-AGENCYs <br /> PORATIONQ PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AR✓E�A CODE �i — <br /> 1 L' 9i4/ <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4_1_4P- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bindirate 1 SELF-INSURED 0 2 GUARANTEE Q 3 INSURANCE 0 4 SURETY BOND <br /> =5 LETTER OF CREDIT 0 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: 1.0 II.❑ <br /> THIS FORM HAS BEEN CO TED UNL#R PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MOONTH/DAY/YEAR <br /> �S(uchih-.L47 r�.} J9v <br /> GI P � Gipt9 [�. �l• 1�7 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> MI <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONALSUPVISOR-DISTRICT CODE -t7P111pAfAL <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 /> i <br /> FORM a(3/93) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR=3A-R7 <br />