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• . .r • Pp,S OVR eg <br /> STATE OF CALIFORNIA ° <br /> 9 <br /> STATE WATER RESOURCES CONTROL BOARD w m <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a Y. <br /> !J •CSI IFOR N^ <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY F-1 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM E] 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �' r <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA&R FACILITY NAME NAME OF OPERATOR <br /> (kCC�n S� 10 ) —502. <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> .35 IBJ, C-he-ro K L_an,_ G`M <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> L_vd i CA Q 5__11`1 D a(moi' - <br /> TO INDICATE CORPORATION 0 INDIVIDUAL =PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR / IF INDIAN Ix OF TANKAT SITE E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDSL3';'-DD <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> D ,S: NAME(LAST,FIRST) i PHONE#WITH AREA CODE DR YS: NAME(LAST,FIRST) 20cl __3(09_ <br /> �p- BI Q4 <br /> cSYI�+ }�r� ac?Q-3to -►SaS irlCzrC l f CAR <br /> � <br /> NIG TS: NAME(LAS ST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRS _ /77_ 5 <br /> Kris a0q - 33a o n <br /> PHONE#WITH A EA <br /> Ii. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME _ CAR F AD RESS INFORMATION <br /> ` <br /> MAILING OR STREET ADDRESS ✓ tax to indicate 0 INDIVIDUAL AGENCY STATE-AGENCY <br /> x5 a5 fACORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME 9TATE ZIP CODE PHONE#WITH AREA CODE <br /> -�Dr G9- 32� L(��-5�3- �-1 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF WNER CA E OF ADDRESS INFORMATION <br /> lit 1 c-.Y)0-4/ , RMce.& ► '. kn <br /> MAILING OR STREET ADDRESS ✓ tax b Indicate INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> 5 a 5 G_t CORPORATION PARTNERSHIP E�] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE 2 PHONE#WITH AREA CODE <br /> Q cam` 2,C 1— - ack7 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4T41_j0jajqjbj(Q v <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 2 GUARANTEE E:] 3 INSURANCE 0 4 SURETY BOND <br /> 5 LETTER OF CREDIT (]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 II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= II.X III. <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(PRINTED&SIGNATURE) APPLICANTS TITLE <br /> .� DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# ���y <br /> Z 0 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 01— 03•6o 340 <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 /> FORM A(5-91) FOR0033A-5 <br />