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PeeouRces c <br /> 0 0 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> C1.IFON"' <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE _ <br /> MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLCSED SI�� <br /> ONE ITEM a 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DffpFA6T,NAME NAME OF OPERATOR ' <br /> ADDRESS NE EST CROSS STREET PARCEL#(OPTIONAL) <br /> I y cou�-t, C K firo►�• eo,S I'rn <br /> �5-9 <br /> CITY ME STATE ZI C E TE PH NE#WITH AREA CODE. <br /> c k n CA �a y ��9 y3�?o a I <br /> ✓ BOX ��{ <br /> TO114DICATE LXJ CORPORATION E=1 INDIVIDUAL E:1 PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY �I FEDERAL-AGENCY t, <br /> �` DISTRICTS <br /> TYPE OF BUSINESS FM 1 GAS STATION 2 DISTRIBUTOR / IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM a 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDAP")-optional <br /> DAYS: AME(LAST,FIRST) P ONNEE IL <br /> to <br /> AREA CODE D S: NAME(LAS/T,FIRST) ��t/�6 <br /> �t��faw.5 Im!k-e .209 / / 3'_a� Q/`i5% !��It'S (O C7 OD �I <br /> NIGHTS: NAME(L ST,FIRST) PTAONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) (�' �� ,L/_ ? .✓OD <br /> AGO.27`l- �57� �y��e.ti,1e evlc <br /> PHON <br /> If. PROPER WNER INFORMATION• MUST BE COMPLETED <br /> NAM ro CA}E OF ADDRESS INFORMATION <br /> 0e�� LO�(�-5 C�✓`1`�5! <br /> MAILING OR STREET �S � � � D ✓ box biMicate 0 INDIVIDUAL OLOCAL-AGENCY (� STATE-AGENCY <br /> 2�QJ�6 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY ME ST E ZIP UE P Nc w"TH AREA CODE <br /> Oo Q>� 46 6-31—0 733 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> E fmaw / C E OF ADDRES FORMATION <br /> IF <br /> TREE` DDRESS ✓ box to indicate C INDIVIDUAL LOCAL-AGENCY C STATE-AGENCY 6 <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERALAGEN';f <br /> /O9MZIP 0 P��E W'H�EA ODE <br /> 3 v 733 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 74. [4-]- p a 1 0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> - �2 GUARANTEE N <br /> ✓ box b indicate 1 SELFINSURED � 3 INSURANCE 0 4 SURETY BOND <br /> 5 LETTEP OF CREDIT C 6 EXEMPTION 0 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or li is the <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. it. <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 <br /> E((P��RIINTED&SIGNATU APPLICANTS TITLE DATES MONT YNEAR <br /> F✓'f� )4( 6�elhQ 1 awuea L'vt� 6/ <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 0 � <br /> LOCATIO CODE -OPTIONAL CENSUS TRACT# -OPTIONA4 SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 3 1 IILn/ _ <br /> THIS FORM MUST BE ACCO PANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ON!;� ' + <br /> FORM A(5-91) FOR0033A-5 <br /> O l <br />