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STATE OF CAUFORMA <br /> STATE WATER RESOURCES CONTROL BOARD yPiyv�, , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A , <br /> ��y� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE le a <br /> MARK ONLY 1 9 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O T PERMANENTLY CLOSED SITE <br /> ONE ITEM a 2 INTERIM PERMIT 0 a AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OrGI IDTY AME 1✓2ul * IZ05 NAME OF OPERATOR <br /> ADDRESS '1�' NEARESTGROSS STREET PARCEL#(OPTKI <br /> Garr►bf' Dr. _OU <br /> 1se <br /> CITY N E STATE ZIP CODE SITE PHONE i WITH AREA CODE <br /> hr CA 5330 <br /> ✓Box WCORPORATKIN E__1 NDMOUAL 0 PARTNERSHIP O LOCAL-AGENCY ED COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 10 dUSTBaW*.�a�gv1cy.mMWsmaroman¢a auperawdm son,HClonmoir..Nmo ewesmaUST <br /> TPE OF BUSINESS Id 1 GAS STATION 0 2 DISTRIBUTOR Q ✓IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#Toptwae <br /> 0 3 FARM Q A PROCESSOR Q S OTHEROR RESATION <br /> TRUST <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> &D�AYS: NAM (LAST,FIRST) n PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE R WITH AREA ECODEVtWr er 1 I qNIGHTS: NMAE FIRST) PHONEI WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE#WITH AREA <br /> erstf II I 14 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> r n <br /> MAILING OR STREET ADDRESS ✓ I)MMMule QWDNIDUAL [=1LOCAL-AGENCYSTATE-AGENCY <br /> vadW a �e- CORPORATKW O PARTNERSHIP 0 COIMTY-AGENCY O FEDERAL-AGENCY <br /> CIT/NAME STATE DP CODE P ON1EWITH AREA CODE <br /> r meat G,d II eAA - I <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER h rke}i (..OM CARE OF ADDRESS INFORMATION <br /> a✓ <br /> MAILING OR STREET ADDRESS I 1 ✓ boalo Mtge Q WIVIDUAL O LOCAL-AGENCY t=1 STATE AGENCY <br /> (J (, C<CORPORATON Q PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATEZIP CODE PHONE#WITH AREA CODE// <br /> -fo I V- - & <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> f 5 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓bMbMMY 0 1 SELF-NSURED W2 GUARANTEE Q 3 INSURANCE 0 A SIRETYBONO O 5 LETTEROFCREDIT =1 8 EXEMPTION 1&T STATE FUND <br /> [1)8 STATE RIND&CHIEF FINANCIAL OFFICER LETTER CD9STATE RIND&CERTIFICATE OF DEPOSIT O IB LOCAL GOYT.MECHANISM 0MOTHER <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 11.0 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAYNEAR <br /> KIF 14 GIen lno ,taQiXu Td -r� <br /> or- �6to I i `o Z <br /> LOCAL AGENCY USE ONL <br /> COUNTY A' JURISDICTION# FACILITY M <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> �' <br /> THIS FORM MUST BE ACCOMPANIED BY AT LE (1)OR MORE PERMIT APPLICATION- FORM B,UNLESS T' IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(695) OWNER MUST FILE THIS FORM Y.,,,,THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUA._ ORAGE TANK REGULATIONS�,` 7/1 ql q d <br />