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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F7 2 INTERIM PERMIT 4 AMENDED PERMIT IQ a TEMPORARY SITE CLOSURE 5 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBAOR FACILITVNAME / �g <br /> NAME -lceoOp <br /> ADDRESS NEAREST CROSS STREET PARCELA(OPIONAL) <br /> 7S <br /> CITY NAME STATE LP CODE SITE PHONE i WITH AREA CODE <br /> �77aaL'7o CA 7 <br /> BOX <br /> To INDICATE CORPORATION Q INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY M COUNTY-AGENCY' O STATE AGENCY O FEDERAL- <br /> AGENCY' <br /> DISTRICTS' <br /> If owner of UST Is a public agency,maplete the following:nanle of Supervisor of division.section,or office which operates the UST <br /> TYPE OF BUSINESS �1 GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN a OF TAN AT SITE E.P.q. I.D.i(optimal) <br /> RESEfl INDIAN <br /> O 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TE <br /> LANOS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRS PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> �� Za G Maj�S 3s�/ <br /> NIGHTS: NAME(LAST,FIRST� _ / PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PVKONE i WITH AREA CODE <br /> G� � <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAIL/INGOfl STREE ADDRE�SS,I ✓ bM bIMbW 0 INDIVIDUAL EDLOCAL-AGENCYO STATE-AGENCY <br /> "-� d CORPORATION 0 PARTNERSHIP =COLIM-AGENCY O FEDERALAGEKCY <br /> CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE <br /> Gcs v 950 r/4§-)-31W-3W <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAMEOFOfVNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREE/]ADDR/ESS �+ ✓bot bin&ale INDIVIDUAL O LOCAL-AGENCY I)STATE-AGENCY <br /> Jr7 4� /Y . % / V� ✓v�/Z O CORPORATION PARTNERSHIP COUNTY AGENCY FEDERALAGENCY <br /> CITY NAME gTAIE ZIP CODE HONE I WITH AREA CODE <br /> ,3�-3� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(9%)322-9669 if quesgons arise. <br /> TY(TK) HQ M44- -I__ [ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ,/IbXbbaoW 1 SELF-INSURED 2 GUARANTEE 3INSURANCE 4 SURETY BOND <br /> O 5 LETTEROFCREDIT O&EXEMPTION O W 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.O II. Ill.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTYx JURISDICTION a FACILITY t <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS, -OPTIONAL 9UPVISOR- TRICT -OPTpAIAL <br /> 0 322 OffB` <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) FOROW3A-F <br /> '%jYf y <br />