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STATE OF CALIFORNIA o" <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE •a�N'' <br /> MARK ONLY S NEW PERMIT 3 RENEWAL PERMIT F75 CHANGE OF INFORMATION 7 PERMANENTLY CLOS SIE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> 4-- t T + <br /> ©j 1 dna 7`e-javen --` ore � NEAREST CROSS STREET PARCEL (OPTIONAL) <br /> ADDRESS <br /> ���� K (-.t <br /> N- STATE ZIP CODE <br /> CITYAME SITE PHONE#WITH AREA CODE <br /> CA Gc�> <br /> ✓BOX CORPORATION (] INDIVIDUAL 0 PARTNERSHIP L::] L CAL-DISTRICTS I] COUNTY-AGENCY' STATE-AGENCY' FEDERAL-AGENCY' <br /> TO INDICATE <br /> 'N ownerol UST is a pubbe agency,complete the following name d supervisor of division,section or office which operates the UST <br /> �INOI SITE E.P.A. I.D.#{optioaalJ <br /> TYPEOFBUSINESS t GASSTATION 0 2 DISTRIBUTOR R3 FARM 4 PROCESSOR = 5 OTHER OR 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> P yE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> DAYS: NAME(LAST,FIRST) i f7 <br /> iG PHONE B WITH AREA CODE <br /> NIGHTS: NAME11�,LAST.FIRST) PHONE#WITH AREA GODS NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> CARE OF ADDRESS INFCJRMATION <br /> NAME <br /> 2t'r�fi <br /> - ✓ hos to indcale INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> MAILING OR STREET ADDRESS <br /> CORPORATION PARTNERSHIP �_] COUNTY-AGENCY 0FEDERAL-AGENCY <br /> STATE <br /> ZIP CODE 9 J y PHONE W�I�TH AFFA COOOE, C;� <br /> CITY NAME ' r� 1 (�! t 1 ��I IL[7 +J ( �7 5,:,0b <br /> f!. <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF R14JNER CARE OF ADDRESS INFC)RtAgTION �' r <br /> MAILING OR STREET ADDRESS ✓ boxioindlmte ED INDIVIDUAL �} LOCAL-AGENCY STATE-AGENCY <br /> _N 3X CORPORATION a PARTNERSHIP [] COUNTY-AGENCY FEDERAL-AGENCY <br /> STAT,E� ZIIPP L C�O� PH <br /> DE ONE#WITH AREA CODE <br /> CITY NAME lfw / �f�C �7 C� l• "' <br /> 1V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call (916)322-9669 if questionsrise2. <br /> TY(TK) HQ 4 4- - r 4 �- �J 1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓hox to Ind rite l= t SELF-INSURED =2 GUARANTEE = 3 INSURANCE =4 SURETY BOND 5 LETTER OF CREDIT 0 6 EXEMPTION I�7 STATE FUND <br /> Q 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND&CERTIFICATE OF DEPOSIT I= to LOCAL GOVT.MECHANISM ED 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: <br /> THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWRNN_ERr'31ITLE DATE MONTHIDAYIYEAR <br /> TANK OWNEKS NAME(PRINTED&SIGNATURE) /t ° y (0�'f?r- I G7 <br /> COF II4rI l/4} J!fr7 <br /> LOCAL AGENCY tISE ONLY <br /> COUNTY# JURISDICTION# FACILITY <br /> EE <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT V&T(1)OR MORE PERMIT APPLICATION- FORM B.UNLESS IS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FOROW THE LOCAL AGENCY IMPLEMENTING THE UNDERGROWORAGE TANK REGULATIONS <br /> FORMA(6-95) <br />