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0 0 e.ounce. <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR ACILITY NAME NAME OF OPERATO <br /> ADDRESS � Ar <br /> NEAREST CROSS STREET PARCEL#(OPTIO AL) <br /> S <br /> CITY NAME STATEZIP CODE SITE PHONE#WITH AREA CODE <br /> Sra c I CA 6 Z 01 1`1 P3— o 19 q <br /> ✓BOX CORPORATION E�] INDIVIDUAL Ej PARTNERSHIF Q LOCAL-AGENCY COUNTY-AGENCYSTATE-AGENCY' FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> If owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS [j2'_1 GAS STATION 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM Q 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> /9ry4tre'-' .� L-2,tvida - <br /> NIGHTS: NAME(LAST,FIRST) PH NE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEs Lu,-t all <br /> e . LLC <br /> C CARE OF ADDRESS INFORMATION <br /> l�iti S <br /> MAILING OR STREET ADDRES ✓ box to indicate INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> /— 0 /3 ZU [,X CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Iry /1 � S o '7 o - q66- <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> �t&ISri s L ,� L L C. <br /> MAILINGOR <br /> VOR/S'T�REET ADD SS ✓ boxio indicate 0 INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> 1 f U 2 CORPORATION PARTNERSHIP (] COUNTY-AGENCY FEDERAL-AGENCY <br /> PHONE#WITH AREA CODE <br /> CITY NAME STATE ZIP CODE <br /> 9 r 20Lac—S—ti2 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED O 2 GUARANTEE =3 INSURANCE =4 SURETY BOND 0 5 LETTER OF CREDIT O 6 EXEMPTION 7 STATE FUND <br /> 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O 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: I.a II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATOR TANK OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> ,'u',,d <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# Q 6 r 77 <br /> m o (a <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL J <br /> 0 <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 /> FORMA(6-95) OWNER MUST FILE THIS FOFW THE LOCAL AGENCY IMPLEMENTING THE UNDERGRW STORAGE TANK REGULATIONS <br />