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STATEOFCALIFORMA <br /> STATE WATER RESOURCES CONTROL BOARD T)f <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A-- <br /> COMPLETE THIS FORM FOR EACH FACILrrY/SRE <br /> NARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT [:j 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT 0 4 AMENDED PERMIT O S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY N E NAMEOFOPE TOP <br /> RCO �OLC• X21 'Zo k es QoA��nl u111 <br /> ADDRESS NEAREST CROSS ST EET PARCELs(OPTIONAL) <br /> 441r\ vJ . V�cA L,I.Tc��nT <br /> CIN NAME STATE ZIP Dqq ESITE PH #WITH AREA CODE <br /> S'cock� N CA `1s Lnb ONE-- <br /> ✓ BON( <br /> TO INDICATE Q CORPORATION INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY AGENCY' Q STATE AGENCYQ FEDERAL AGENCY <br /> H owner of UST Is a public agency,complete the following:name of Sul»rvior of division,sedpn.DISTRICTS m office which operates the UST <br /> TYPE OF BUSINESS1 GAS STATION 2 DISTRIBUTOR 0 ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.*IcWmNte# <br /> O 3 FARM Q 4 PROCESSOR Q 5 OTHER RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> [NIGHT <br /> AYSNAME(LAST,FIRSn PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> S: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> akK N x Rose ROo s 'FINJV , x Roie q . ' OG u s <br /> MAILING OR STREET ADDRESS 1 ✓ b>a blMkaN Q INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY <br /> 1� rstw`P} S'C Q CORPORATION N PARTNERSHIP Q COUNTY AGENCY Q FEDERAL AGENCY <br /> CITY NAME STATE ZIP DE Pt�oNE a KITH AREA CODE <br /> 1-rut� �N Q APs 2-0la l2oq` 9b� -1Wb <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER^n M rVro` T� _ CARE OF ADDRESS INFORMATION <br /> MAILING OR STRF�T.FRESS 0. Q ✓ 1pr biMkaie Q INDIVIDUAL Q LOCAL Q STATE-AGENCY <br /> 'O N OY CORPORATION Q PARTNERSHIP <br /> Q COUMYAGENCV Q FEDERALAGENCY <br /> CITY NAME r� BWE ZIP CODE q PH/ONE WITH AREA COD`E� .r <br /> PTRTesL GO1O — 3l 771 1O 'S COY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO R41- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> but eftaM t SELF INSURED Q 2 GUARANTEE Q 3 INSURANCE <br /> Q 5 LETTEROFCREDT Q A SUREN BONG <br /> Q 8 E%EMPTION Q 89 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.[—] I.FII� <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAM RINTED 5 SIGNED) OWNERS TITLE f�pEAR <br /> DATE � �C <br /> � % . 11` 11 JJ <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# RISDICTK)N# <br /> FACILff V# <br /> OZ7 m a <br /> LOCATION CODE -OPTIONAL CENSUSTRACTS -OP77ONAL SUPVISOR-DISTRICT CODE .OPT)ONAL E:71 <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 /> FORMA(1113) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> iOn007.3AAT <br /> tir �� <br />