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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRY/Sr1E <br /> MARK DN 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY C <br /> ONE ITEM Q2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> DDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 31 N F G I_J.40 CITYNAME9TATE ZI'CODE ;L+2— SITE PHONE#WITH AREA CODE <br /> (,L-00w) <br /> Cpl ` <br /> TO INDICATE BOX O CORPORATION INDIVIDUAL IQ PARTNERSHIP 0 LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE AGENCY• Q FEDERAL#GENCY' <br /> DISTRICTS' <br /> •N owner of UST la a public agency,conplete the following:name of Supervisor of division,section,or o6ioe which operates the UST <br /> I <br /> F I <br /> TYPE OF BUSINESS O 1 GAS STATION = 2 DISTRIBUTOR ✓ INDIAN #OF TANKS AT SITE E.P.A. I.D.•(cWianel/ <br /> RESERVATION <br /> IQ 3 FARM E__) 4 PROCESSOR = 5 OTHER OR TRUST LANDS QGU Issz.,+6 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> Z <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> (�)S <br /> MAILING OR STREET ADDRESS ✓Bov bh#k#s Q INDIVIDUAL Q LOCAL-AGENCY QSTATE-AGENCY <br /> Z 6 F D. Q CORPORATION Q PARTNERSHIP Q COUNTY AGENCY Q FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> rN-N- SIC) S -724 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNERCARE OF ADDRESS INFORMATION <br /> �,4rxuSI,F 40 <br /> MAILING OR STREET ADDRESS p� ✓ Oorov& ws .INDIVIDUAL Q LOCAL Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP O COUNTYAGENCY Q FEDEML#GENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HOF4 4- 7 1 D <br /> r <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ �s bMtllau Q 1 SELF-INSURED 0 2 GUARANTEE I%3 INSURANCE Q 4 SURETY BOND <br /> Q 5 LETTEROFCREDIT Q 6 EXEMPTION UZI 99 OTHER w <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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O I.O IN. <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) OWNERSTITLE DATE MONTWDAYNEAfl <br /> l <br /> Ewl7 le �- ek.4� / o t-e— s1zzl�y <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LTIT 1 1 1-71 -J <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOnG-DISTflfCT CODE -OP7/0NA1. <br /> �_ ) ' , <br /> THIS FORM MUST BE ACCOMPANIED BY AT CT(1)OR MORE PERMIT APPLICATION- FORM B,UM -HIS IS A CHANGE OF SITE INFORMATION OpLY. <br /> OWNER MUST FILE THIS FOAm##TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRIy0 STORAGE TANK REGULATIONS <br /> FORM A(3r93) -QQLG ave e-vo ec` _zI /�}.Q & ac{lC� = <br /> � y-io-tib . �!a r� >A�, <br />