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1 _ <br /> STATE OF CALIFORNIA <br /> "STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> V 1 Y✓ c <br /> COMPLETE THIS FORM FOR EACH F CILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ <br /> ,7 <br /> PEA IANENTLY CLOSGD SIE <br /> ONE REM ❑ 2 INTERIM PERMIT F7 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE \'. <br /> I. FACILITY/SITE INFORMATION& ADDRESS•(MUST BE COMPLETED) <br /> OSAORFACIUTYNAME NAME OF OPE RATOR <br /> Iv C lT77 <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> gd <br /> CITY NAME STATE <br /> ca, ZIP CODE SITE PHO -�WI AREA CODE <br /> 132A 53.7 b �s- dos <br /> I/ BOX <br /> TOINDICATE ORPORATION Q INDIVIDUAL Q PARTNERSHIP LOCAL-AGENCY Q COUNTY.AC.ENCY Q STATE AGENCY Q FEDERAL AGENCY <br /> DISTRICTS <br /> r��7 <br /> S ❑ 1 OAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN s OF TANKS AT SITE E.P.A. I.D.A(Optmmf) <br /> RESERVATION <br /> 3 FARM r— A PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> GAYS: NA (LAST,FIRST) PHONE A WITH AREA CODE DAYS: Myp E(LAST,FIRST) <br /> NIGHTS: NAME(LAST.FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST-FIRST) <br /> 4 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 5 <br /> MAIL•NG OR STREET ADDRESS ✓ pp,yl ,mi Q INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> 5 T Q CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEOERALAGENCY <br /> CIT(NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> �k PL c,L s C_b <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) ' <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MCSo N, ►zU�— M <br /> MAILING OR STREET ADDRESS ✓ � Q INDIVIDUALQ L000.-AGENCY QSTATE-AGENCY <br /> [A V CORPORATION Q PARTNERSHIP Q COVNTYAGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> WGS'r G R M EIu. G1t�- �I <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 157�L.V %I b <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ 5w citlkar Q I SELFI16URED Q 2 GUARANTEE Q I INSURANCE Q 4 SURETY BOND <br /> 0 5 LETTEROFCREDIT Q B EXEMPTION Q 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: L❑ II-❑ IIL <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY w� <br /> COUNTY a JURISDICTION 1 FACILITY s <br /> Mwa;541 I c) 6 <br /> LOCATIO -OPTIONAL (CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -CPT(ONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. , <br /> FORM AIS9q <br /> FONO=A5 <br /> a• <br /> V..r <br />