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a � <br /> STATE OF CALIFORNIA <br /> z STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SM c4tPopt <br /> MARK ONLY 0 i NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE <br /> a ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE e) JM K <br /> 1. FACILITY/SITE INFORMATION& <br /> ✓ �/� � i-"f ADDfRES�!S I-(MUST BE COMPLETED) <br /> DBA OC /LI <br /> ADDRESS <br /> N� <br /> L U/ MVr (- 1.6Y/ <br /> - <br /> CITY NAMr5STASITP PHONE#WITH AREA COJ& <br /> CA <br /> �" `L , ! 1/ <br /> BOX <br /> TO INDICATE CORPORATION =INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCYSTATE-AGENCYFEDERAL-AGENCY• <br /> DISTRICTS' <br /> If owner of UST Is a public agency,complete the folwMq:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS %L t GAS STATION Q 2 DISTRIBUTOR � R/ IF INDIAN X OF TANKS AT SITE E.P.A. 11..Dom#� tb7al <br /> 0 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS "7"e+e v'i/i/{�/ i 3 4 9 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FI ONE#WITH AF�EA DE YS: E jk13�T,FI Ft3 f4!??�WONE 7i WITH EA D <br /> CIO <br /> N HT& NAME(LAST, ST) PHONE X WITH AREA COD NIGHTS:NAME( T,F PHONE a WITH CODE <br /> If. PROPERTY OOW+NER INFORMATION• MUST BE COMPLETED 4+ <br /> NAME /AGO s d co CARE ESS poff INF TK);yi <br /> MAILING STREETDESS ✓boxbindicaq f�INDIVIDUAL- Q LOCAL-AGENCY STATE-A NCY <br /> 4 Q GQ 3 CORPORATION (] PARTNERSHIP (]COUNTY-AGENCY '"` ]FEDERAL-AGENCY <br /> CIN NAMES 3 yjF� O� PHONE WITH AREA CODE v <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF Eft O „c�. CARME ATIO <br /> Ax <br /> CCPRUCYC 7S <br /> MAILI G Q"TREET ADDRESS ✓box b indicate [=1 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> r{•�}V'� (//�/Lyf') PORATION 0 PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY <br /> 1 11 <br /> CITY NAME STAI&P P CODE PNON ATH AREA CODE ; <br /> I IV.BOARD OF EQUALIZATION UST STORAGE,FEq ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ4-1- 1010101$10104 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box b 1 SELF-INSURED 2 GUARANTEE (]3 INSURANCE (�4 SURETY BOND <br /> (]5 LETTER OF CREDIT (]5 EXEMPTION 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. 11.O III <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTH/DAY/YEAR <br /> S <br /> LOCAL AGENCY USE ONLY <br /> COJ.�L=J JURISDICTION# FACILITY# / <br /> LOCATION CODE-OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OiPTIIONAL <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 FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATMIS <br /> FORM A(3193) FOR0M-R7 <br />