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,OUR Cs <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E� 7 PERMANENTLY CLOSE SITE <br /> ONE ITEM 2 INTERIM PERMIT C 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE i <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 1 <br /> R FACILITY <br /> -De�,C�C/LI NA `/-I- N�OF OP rOR <br /> 1 ►D <br /> ADDbw • — NEAREST OSS STREET PARCELu(0 IONAL) <br /> CITY NAME STATE ZIP C,Op�� SITE PHONE#WITH AREA CODE <br /> I 2 -3 � <br /> ,,, I _ CA <br /> 0 INDICATE CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS I GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> D6S��(�T,FIRST) �� HON E#WITH AREA CODE DAYS: NAME(LAST,FIRST) 1 O ��y�'�'� <br /> NI HTS: NAME(LAST,FIR PHON #WITH AREA CODE NI H S. NAME(LAST,FIR / r l f„�` -�f� <br /> IVAI/l <br /> ff <br /> PHQUFJ <br /> II. PROPERTY OWN R INFORMATION- MUST BE COMPLETED <br /> NAME - CARE OF ADDRESS INFORMATION <br /> _'5oil m av1 <br /> MAILING OR STREET AD RESS ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CI NAME STAT ZIP OD NE#WITH AREA CODE <br /> I� a_ 2�I- �CIM6)k�rb-Lg <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NA OF 4T i /�_ a CARE OF ADDRESS INFORMATION <br /> �G OR STREET ADD E S IIF '' ✓ box to indicate 0 INDIVIDUAL = LOCAL-AGENCY STATE-AGENCY <br /> Lo <br /> 'XJL' CORPORATION 0 PARTNERSHIP = COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CI AME •� STATE ZIP ODS._ 0 P ONE# IT��CODE <br /> _0 na <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ L4 4]- 1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate [V-, SELF-INSURED [=1 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> = 5 LETTEROFCREDIT = 6 EXEMPTION E71 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. <br /> THIS FORM HAS BEEN COMPLETED R PEN TV OF UPY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> AANT'S NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE DATE MONT /DAY/YEAR <br /> VLw"l 1 RD <br /> yx <br /> 1 2 <br /> LOCAL AGENCY USE ONLY IF <br /> COUNTY# JURISDICTION# FACILITY# <br /> -L-I <br /> LOCATION -OPTIONAL !CENSUS # -OPTIONAL I S��DDISTRICT CODE -OPTIONAL ' <br /> VTHIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> !'ORIJ A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 10 0 �� FOR0033A-R6 <br />