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k 3' <br /> tgoUq - <br /> " STATE OF CAUFORNIA �` ?o <br /> STATE WATER RESOURCES CONTROL BOARD F 4p�� o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT F_� 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE <br /> ONE RrEM Q 2 INTERIM PERMIT u 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR F9CILITY NAM O� NAME OF OPERATOR <br /> ADDRESS &1,�!'W NEAR STC/ROSSI/ STREET �MM P' 15-1IONA1-30-52 <br /> 7 /V <br /> Y N <br /> CITY NAME If STATE ZIPSITE PHONE#WITH AREA CODE <br /> �crai✓ G�} CaBX <br /> ao �► � 1 qy8 �-� <br /> T DIIC <br /> NTE Q CORPORATIONINDIVIDUAL =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 1 GAS STATION 0 2 DISTRIBUTOR 0 RESEIF R INDIAN #OF TANKS AT SITE E.P.A.` I.D. <br /> #(optional) Q y <br /> 3 FARM Q 4 PROCESSOR = 5 OTHER OR TRUST LANDS c per" <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAS1119, 5f <br /> T,FIRS V �ONE#WITH ARE DE DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE <br /> 62 <br /> NIGHTS ME(LAST,F RST) JP ONE#WITH AREA NIGHTS: NAME(AST,FIRST) PHONE#WITH AREA CODE <br /> ;0 X) 9 /-Soak <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME !A" '` CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS O ,! 0IdkE:11,1tlIVIDUAL LOCAL <br /> -AGENCY STATE-AGENCY <br /> //I ,� CORPORATION [] PARTNERSHIP Q COUNTY-AGENCY 0FEDERAL-AGENCY <br /> CIN NAME STATS ZIP PH��� ITH AR ODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW ER ,j CARE OF ADD SS INFORMATION <br /> MAILING <br /> ��OjjR��STREET ADDRESS' Q ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY <br /> �G/3 //V T ✓ Q CORPORATION 0 PARTNERSHIP 000UNTY-AGENCY +Q FEDERAL-AGENCY <br /> CITY NAME STATE 7JP CQ��h H A COD <br /> y� V - 6 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT • • BI r Call 322- n arise. <br /> TY(TK)C C)4 4- - 3 p 1� .��, ' <br /> V. PETROLEUM UST FINANCIAL RESPONS) Y- IST BE COMPLETE It3ENTIFY THE METHODS) USED <br /> ✓ box b indicate 1 SELF-INSl1R �y Q 2 GUARANTEE Q] 3 INSURANCE 4 SURETY BOND <br /> D 5 LETTEROFCREDIT O 6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS 1-01 tification 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. IL 0 III. <br /> THIS FORM HAS BEY4 COMPLETED.UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINT f NE ) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGE qy- ONLY <br /> COUNTY# JURISDICTION# FACILnY# CI 7N(z <br /> m F clIq Ek] <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 /> OWNER MUST FILE THIS FOR 'ITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO STORAGE TANK REGULATIONS <br /> FORMA(3193) FOR0033A-R7 <br />