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• t60Un C <br /> STATEOFCAUFORNIA ;� yso <br /> STATE WATER RESOURCES CONTROL BOARD F��' S <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A os <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY f NEW PERMIT 0 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMAN TLY CLO E <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE l <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR r <br /> ADDRESS NEARE T CROSS TREET PARCEL N(OPTIONAL) <br /> 777 G .0 Y <br /> x" /,<� <br /> CITY NAME STATE ZIP CO �� / SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓ Box CORPORATION0 INDIVIDUAL [:jPARTNERSHIP Q LOCAL-AGENCY E:]COUNTY-AGENCY' 0 STATE-AGENCY' 0 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 JK I GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE I E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR Q 5 OTHER OR TRUST LANDS c� <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 /> X09 S_35--2_7_5_<D <br /> NIGHTS: NAME(LAST,FIRST] ___ PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 94?--0S� S,Q M6 c / �L .3G 9578 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME , / �J p®�C_ CARE OF ADDRESS INFORMATION <br /> _&=,,,e,42 MAILING OR STREET DRESS/ //v�,/✓ box to indicate INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> 6 <br /> A Q � 7 (]CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY STAT ZIP CO' J! PHONE WITH AREA?3S— 27�� <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) (/ o <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> ,T& ,p <br /> MAILING O TREET AD RESS ✓ box b indicate �DIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> .Q. OX 0 CORPORATION O PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME n JT� <br /> _7 <br /> JS/?IS <br /> STP_ ZIP CO i PH� WITH AREA CODE 2 7;Q <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669ciff questions arise. 7G C <br /> TY(TK) HQ F4-F4--]-1 C21214 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate I SELF-INSURED =2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT 0 6 EXEMPTION 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: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENH Y OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OW R'S TFTLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY QzCh2, t-,7- 897 <br /> COUNTY# JURISDICTION# FACILITY#f 4W(.,9-7 7 <br /> o S I e7 RIO <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMA ONLY. <br /> OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUSTORAGE TANK REGULATIONS <br /> FORM A(3/93) FO <br /> FORM <br />