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STATE OF CALIFORNIA .� 9 <br />STATE WATER RESOURCES CONTROL 50-A AD FORM <br />S <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A Y <br />COMPLETE THIS FORM FOR EACH FACILITYMTE <br />MARK CHLT I NEW PERMIT F-13 RENEWAL PEFIIAiT I,,..J S CHANGE OF TNFOA7.IATIUN 7 PERM-NENTLY CLOSED SITE <br />ONE ITEM El 2 INTERIM PERMR ED s AMENDED PERMIT 6 TTcMFORAFiY SITE CLOSURE <br />1TvAc,Te IMEADUATinu i AnnAlme.- (L1IIAT BE COMPLETED) <br />EMERGENCY CONTACT PERSON (PRIMARY] EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />WY :NAME (LAST. FIRS , PHONE ! WITH AREA COOE+.� DAYS: NAME (LAST, FIRST) PHONE 0 WITH AREA CODE <br />_ _- - __ QlL.L177 X77 1 <br />NIGHTS: NA15W l FIRST) <br />r> <br />IL PROPERTY OW E <br />OR STyt:ET AOOREPS <br />CITY NAW E <br />• WITH <br />INFORMATION - (MUST BE COMPLETED) <br />III. TANK OWNER INF02MATION - (MUST BE COMPLETE <br />F°% . <br />AAI ING OR STREET ADDRESS- _ <br />NAWE (LAST. FIRST) <br />O,F ADDRESS <br />PHONE 6 WITH AREA CODE <br />V, wx 0cdme <br />Q INDIVIDUAL <br />%f_] LOCAL.AGENCY <br />U STATE -AGENCY <br />Ct7AFOR+TC}N <br />CD PARTHEASHM <br />I_] COUNTY -AGENCY <br />CD FEDERAL -AGENCY <br />. •_- <br />�. ��M_ <br />PHO <br />- 4 rLry 1ryi <br />EIt WITH ARF_A CC �Ib^ t - <br />A OF <br />ble"SyTION <br />L l <br />.� W119 Loma <br />WDIVIDUAL <br />0 LOCAL -AGENCY <br />STATE -AGENCY <br />(CGI7FCR4744N <br />PAATHER$HIP <br />[� COUNTY -AGENCY <br />Q FEDERAL-AIIEKY <br />- I YTPrnnF <br />p HONE r WITTi AAEA CODE _ l <br />{+r �b 1 - <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER -Call (916) 922-9669 if questions ariss. <br />TY (TK) HO ' 44- wadmEq <br />- <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED <br />SWANSUREC ED 2 GUARANTEE 0 3 INSURANCE Q A SURETY BOND 0 S LETTER OF CREDIT 0 d E%.EWMON E3 7 STATE FUND <br />Latw4V✓Qu <br />= B STATE FUND i Cl iEF FNANCIAL OFFICER LETTER Q } STATE FUND i CEAT,FICATE OF DEPOSIT 0 Ip LOCAL GOYT. MECHANISE[ d9 OTHER <br />VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal no0cstion and bluing will be sent to the tank owner unless box I or ll Is checked. <br />CHECK ONE BD>t INDICATING WHICH ABOVE ADDRESS SHOJLD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 It, III, <br />TNlS ft?RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY. AND TQ THE BEST OF MY KNOWLEDGE. 1S TRUEAND CORRECT <br />TANK OWNER'S NAME (PRINTED A SIGNATURE) TANK OWNER'S TITLE DATE MONTFUDAYIYEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY N JURISDICTION; FACILITY R <br />:6CATION COE • Op <br />CT70NAL - CENSUS TRACT w -OPTIONAL T�SUPv150R -DISTRICT CODE • DPTk7ATAL <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 (BBS) <br />60_d -amu Lala Aad T �JZ)LwLaH V9117 :130 66-91-6"V <br />