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"WrIllip'jm, *F7 <br /> F STATEOFCAUFORWA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A os <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY CD t NEW PERMIT 0 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE <br />`. ONE ITEM F-1 2 INTERIM PERMIT 0 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE <br /> If I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME NAMEOF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL If(OPTIONAkjt`` " <br /> ,41100 1-. F2 C-MW j �S OLO AJC-MU6 ����` to— 4 LP <br /> CITY NAME STATE ZI GPD SITE PHONE#WITH AREA CODE <br /> CA <br /> V Box <br /> f' TOINDIC TE CORPORATION = INDIVIDUAL = PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCYSTATE-AGENCY' 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 al t GAS STATION E::] 2 DISTRIBUTOR ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> O = RESERVATION <br /> 3 FARM 4 PROCESSOR <br /> 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 1. <br /> J <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> f ' <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> { p 6 <br /> MAILING OR STREET ADDRESSy ✓ box to indicate �•INDIVIDUAL D LOCAL-AGENCY STATE-AGENCY <br />' ,DO oklu <br /> _ <br /> CORPORATION CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY N IE STATE ZIP CODE PHONE WITH AREA CODE <br /> � S -11 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> A I rewa�- <br /> MAI/LI`NG OR SSTREET, DRESS ✓ box to indicate Q jNDIVIDUAL 0 LOCAL-AGENCY =STATE-AGENCY <br /> "'t`V�,/, 1j. G"�{�ML9►�'a � CORPORATION (] PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME: ! _ STATE 7CODE 7PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 - <br />�. V. PETROLEUM UST FINANCIAL.RESPONSIBILITY•(MUST BE COMPLETED)�1DENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED 1 2 GUARANTEE =3 INSURANCE 0 4 SURETY BOND <br /> (� 5 LETTER OF CREDIT 6 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: 1.0 Il.ED, III. <br /> THIS FORM HAS BEEN PLETED UNDER PENALTY OF PERJURY,ANt,70 THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED 8 SIGN9b) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br />` COUNTY# JURISDICTION# FACILITY# <br /> fm <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# •OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> F <br /> THIS FORM MUST BE ACCOMPANIED BY ATL (1)OR MORE PERMIT APPLICATION- FORM B,UNLECs�IS A CHANGE OF SITE INFORMATION ONLY. <br /> I OWNER MUST FILE THIS FORhW THE LOCAL AGENCY IMPLEMENTING THE UNDERGR RAGE TANK REGULATIONS' <br /> I FORM A(3/93) FONOOMWN <br />