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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3,} <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> o <br /> COMPLETE THIS FORM FORE H FACIL Y/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT <br /> ONE ITEM 5 RANGE OF INFORMATION ❑ <br /> ❑j 2 INTERIM PERMIT PERMANENTLY CLOSED SITE <br /> ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> NAME OF OPERATOR <br /> ADDRESS U o''x u� <br /> a S / NEAREST CROSS STREET PARC�ErIOWN�A — <br /> CITY NAME cx�c� S - <br /> G�G STATE ZIP CODE SITE CODE <br /> CA if$ <br /> TOINDIC TE I]COR ATION INDIVIDUAL 0 PARTNERSHIP <br /> LOCAL-AGENCY � COUNTY-AGENCY � STATE-AGENCY <br /> TYPE OF BUSINESS DISTRICTS 0 FEDERAL-AGENCY <br /> 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN MOF TANKS AT SITE E.P.A. I.D.71(optional) <br /> O 3 FARM /O 4 PROCESSOR O 5 OTHER = RES ST LANE <br /> EMERGENCYEMERGENCY CONTACT PERSON (PRIMARY) <br /> DAYS: NAME(LAST,FIRST) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> PHONE x WITH AREA CODE <br /> DAYS: NAME{LAST,FIRST) <br /> _ y <br /> NIGHTS: NAME(LAST,FI ST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> S c; <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED H <br /> NAME <br /> 114r41CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS 4,1 /�C <br /> w1� / ' !, ✓ box bindcate INDIVIDUAL <br /> Lc�x <br /> NAME �~—" OCORPORATION LOCAL-AGENCY 0 STATE AGENCY <br /> CITY I / 0 PARTNERSHIP [] COUNTY-AGENCY FEDERAL-AGENCY <br /> GI <br /> �/ STATE ZIP CODE PHONE#WITH AREA CODE <br /> !!! ( 3 a 3 a Ao 9 -r�3 G <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> [NAOF OWNER <br /> CARE OF ADDRESS INFORMATION <br /> Sc= �� u s <br /> G OR STREET ADDRESS <br /> ✓ box b indicate <br /> INDIVIDUAL LOCAL-AGENCY (� STATE-AGENCY <br /> ME (]CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE M WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ L4 �_ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 1 SELF-INSURED <br /> EJ 5 LETTEROFCREDIT 2 GUARANTEE 0 3 INSURANCE <br /> 6 EXEMPTION �] 99 OTHER 4 SURETY BOND <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 /> I.❑ II. III. <br /> THIS FORM,HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> APPLICANTS TITLE DATE MONTHlDAYiYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY t JURISDICTION n <br /> 311 <br /> 1I FACILITY# FACO Z/ <br /> _OCATION CODE -OPT10NAL lidz / 13 <br /> s CENSUS TRACT 77 -OP7lON — <br /> .2S90 I SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 3 L3 co 3/�/ 7 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATIr <br /> DRM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />