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p�sounc1s c <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W dam, a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A r� . <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> °•�,.°nom,'' <br /> MARK ONLY F7 1 NEW PERMIT F--j 3 RENEWAL PERMIT ff 5 CHANGE OF INFORMATION 7 PERMANENTLY52SED.SITE <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAR FACILITY NAME NA OF OPERATOR <br /> t._��rv(0n a +,u►-� �7 h a ( o n rel+pri <br /> ADDRESSN EST CROSS STR PARCEL#(OPTIONAL) <br /> 905 ,&e n m r, k 1 o I� r� rn v u <br /> CIT 1 k4on ATe CA ZIP <br /> JCODE <br /> �© / t�D5NE478AREA <br /> 5555" <br /> r. ✓BOX CORPORATION 0 INDMDUAL = PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY' 0 STATE-AGENCYFEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> It owner of UST is a public agency,complete the following:name of supervisor of division,sedan or office which operates the UST <br /> j TYPE OF BUSINESS 1 GAS STATION O 2 DISTRIBUTOR Q SE✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RERVATION <br /> 0 3 FARM a 4 PROCESSOR Q 5 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) HONE#W AREA CODE <br /> Ec-r©4 SfrtlA-ena z�w-y'78-s5 s hCV(0rj P140 I n en U 17ce, _PHONEIt <br /> 3 -35 <br /> NIGHTS.aAME(LAST,FIRST) PHONE#WITH AREA CODEIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 1'EL- -oA e. 4Mw,) 2.�q-3(4-I II2..' z v(0y1&ner .nrt 01(ffo - C - 3)-b lnZ3 <br /> E II. ROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> i /'� CARE OF ADDRESS INFORMATION <br /> M IN/G OR S(�ErETT ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> IJP+ <br /> CORPORATION O PARTNERSHIP COUNTY-AGENCY0 FEDERAL-AGENCY <br /> CT1�pMM STATE ODE ONE#WITH AREA CODE <br /> � A N533 Hj0-&42-9500 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> OF OWNER ! E OF ADDR�sS I RMA ION <br /> ev(orl - rod u(71 00 m 6 n l rrn it e� � <br /> M NG ORS ET ADDR S ✓ box to indicate Q INDIVIDUAL = LOCAL-AGENCY STATE-AGENCY <br /> r 4)0 TfCORPORATION = PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITYEn �� ` STE- ZIP CODE 'RE#V� AREA n <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER--Call(916)32222-9669 if questions arise. [JJ�iIJ <br /> TY(TK) HQ 4 4- - 0 I 9 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 0 1 SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE =4 SURETY BOND Q 5 LETTER OF CREDIT 0 6 EXEMPTION O 7 STATE FUND <br /> 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM 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 II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= II.O III. <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 W,ME(PRINTED&SIGNATIJRE) [TANK OWNER'S TITLE DATE MONTHIDAY/YEAR <br /> 37 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE-OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AMST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESM IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORMVn THE LOCAL AGENCY IMPLEMENTING THE UNDERGROMWTORAGE TANK REGULATIONS <br /> FORM A(6-95) <br />