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`✓ ..r <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3��� o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A >s , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �'o 0 <br /> MARK ONLY I NEW PERMIT F—] 3 RENEWAL PERMIT E:] 5 CHANGE OF INFORMATION a 7 PERMA CLOSED.SITE <br /> ONE ITEM El 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACIIJTV NA E NAME OF OPERATO ) 11 CI <br /> o G a At/ e Sc a <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHO E �H AREA CODE <br /> l /7 CA 5�3 -7 /y <br /> ✓BOX Q CORPORATION INDMWA O PARTNERSHIP LOCAL-AGENCY E::]COUNTY-AGENCY' O srATE-AG061 Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 8oenerol USTisapuhreageM.coMlete the WIDwng r of supeM rof dweem,section woffm which weaves the UST <br /> TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR I= RESERVATION #OF TANKS AT SITE E P.A. I.D.#(optional) <br /> 3 FARM Q 4 PROCESSOR = 5 OTHER pRTRUSTIANOS 4t—dO 'X, <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LA T,FIRST) PHONE#rw AWEA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> a a ho11Aa/�Q / <br /> NIGHTS: NAME(LAST,FIR / PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Ct v,L e ec b C 7i <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFDI <br /> NAME 1 ,z CARE OF ADDRESS INFORMATION <br /> /\O �/ �//4J "va a/'L <br /> MAILING OR STREET ADDRESS ✓ lzxb ` -' INDNIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> y4�/ Af / O CORPORATION O PARTNERSHIP D COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAMESTATE ZIP CODE HONE#WITH AREA CODE <br /> .c1 e 5 2- <br /> 111. <br /> 111. TANK OWNER INFORM TION-(MUST BE COMPLETED) <br /> NA7 OWNERCARE OF ADDRESS INFORMATION <br /> 1� S a / <br /> mAuNd OR STREET ADDRESS ✓ bor to it rfl. L_J DIVIDUAL Q LOCAL-AGENCY O STATE-AGENCY <br /> j &C- � s Q CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CT'NAME/ ` STATE ZIP CODE / ONE WITH AREA C06-E, <br /> ✓, <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)-IDENTIFY THE METHOD(S) USED <br /> ✓Cosrondrate I SELF-INSURED 0 2 GUARANTEE INSURANCE =4 SURETY BOND 0 5 LETTER OF CREDIT =e EXEMPTION O 7 STATE FUND <br /> 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER E= 9STATE RIND&CERNFICATE OF DEPOSIT O 10 LOCALGOVT.MECHANISM = 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.Q <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TA K W�L6R'SAIAtdEtp"D51QNE) 9� , / T NK OWNER'S TITLE DATE MONTWDAY/VE�A-Rr� <br /> LOCAL <br /> COUNTY# JURISDICTION# FACILITY#QQIa��� <br /> m P& / <br /> LOCATION CODE-OPTIONAL CENSUSTRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS F4 VITH THE LOCAL AGENCY IMPLEMENTING THE UNDERG`ID STORAGE TANK REGULATIONS <br /> FORMA(6-95) �/ <br />