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STATE OF CALIFORNIA ,• c�. <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ae <br /> fV/ COMPLETE THIS FORM FOR EACtLIPACILITYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY Qffg <br /> ONE ITEM O 2 INTERIM PERMIT F-1 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE / <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACILpI ,NAME NAMEOFOPERATOR <br /> n t.L° � d%. r.1 a h <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIDNA0 <br /> W °170 e,�p 611 In= <br /> CITY NAME STATE ZIP CODE SITE PHONE AREA CODE <br /> L CA 1 259-30 (Zo )Z73 - 7rT <br /> ✓ BOX <br /> TOINDICAIERPORATION INDIVIDUAL [__1 PARTNERSHIP LOCAL-AGENCY 0 COUNTY AGENCY STATE-AGENCY (] FEDERALAGEWY <br /> DISTRICTS <br /> TYPE OF BUSINESS E i GGAS STATION Q 2 DISTRIBUTOfl O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal)RESERVATION <br /> 0 3 FARM O 4 PROCESSOR [_-] 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) <br /> LoU YN G 10a tit. 'ZCq-' zq g 73 <br /> NIGHTS: NAME(LAST,FIRS PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) A CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> C�{c.,� Cor orA'+�-1� o✓I <br /> MAILING OR STREET ADDRESS ✓Emb lfAkaM I1 INDIVIDUAL M LOCAL-AGENCY O STATE-AGENCY <br /> SVV �'- HI�F>^ Q RPORATION O PARTNERSHIP F]COUNTYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAMEZIP CODE PHONE#WITH AREA CODE <br /> BTATE <br /> �n u z FrSoyv 1G,o2 y3�-obQO <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOFOWNER �- CARE OF ADDRESS INFORMATION <br /> GSMt S <br /> MAILING OR STREET ADDRESS bo bindVW Q INDIVIDUAL ED LOCALAGENCY O STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNrYAGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - p 3 v <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Sox b inBlcaie O 1 SELF-INSURED [-12 GUARANTEE [;I URANCE 0 4 SURETY BOND <br /> O 5 IETTEROFCREDT O6 EXEMPTION EI 99 OTHER 71 <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.[::] it.L��J— III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> �v 10 0 ts3 <br /> LOCATION CODE - 710NAhJ CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL — <br /> �i <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(591) FORM3A 5 <br /> /A� �� <br />