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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD syd�, m <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE In <br /> MARK ONLY pr i NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CLO ED.SITE —y <br /> ONE ITEM E:] 2 INTERIM PERMIT Q 4 AMENDED PERMIT , 6 TEMPORARY SITE CLOSURE <br /> lls <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR /� <br /> O PcQG baL-ww I (ao /��aln41hh0 <br /> ADDRESS NEAREST CROSS STREET PARCEL4 OPTIONAL) <br /> 5-G co a �o LA lap o0 7-r 7 <br /> CITY NAME STATE ZIP CODE SITE PHONE&WITH AREA CODE <br /> c a CA f rj3 0 12oc, ja2-ca.-7o <br /> ✓BOX 0 CORPORATION 0 INDMOUAL IPPARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> &ownerof UST is a public agency,wirykle the 1010winq name of sweNsaruf dwaion,section oroBce which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR0 ✓IF INDIAN R OF TANKS AT SITE E.P.A. L D.X(0ptbm1) <br /> RESERVATION <br /> Q 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE w WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE w WITH AREA CODE <br /> �AUA.IimApa- l-�LfO'- Z-0370 vz DHM o187--<)376 <br /> NIGHTS: NAME(LAST,FIRST) P NE Y WITH AREA CODE I NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> YyOf_I S/o <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME 1\ CARE OF ADDRESS INFORMATION <br /> A�.W rK M VLKO <br /> M INGORSTREET ADDRESS ✓ boxbsloSrsle D WOMOUAL O LOCAL-AGENCY 0STATE-AGENCY <br /> (0� P 0 CORPORATION PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONEM WITHAREACODE <br /> b-rwtoP A4 T33 tri zo za <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 1ILpSLc 61(00 <br /> MAILING OR STREET ADDRESS ^ ✓ boxbintlirale 0INDMDUAL EDLOCAL-AGENCY =1STATE-AGENCY <br /> .Q N PW, O CORPORATION J5 PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEP HE Y WITH AREA CODE <br /> go <br /> f33 9492-03 <br /> IV.BOARD OF EQUALIZATION UST STORAGEFEEACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 �p- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED C1,0 .* 1,2 yYf <br /> ✓box to inGcaLe 0 1 SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND 0 5 LETTEROFCREDrr O 6 EXEMPTION Lr T STATE FUND <br /> O8 STATE FUND&CHIEF FINANCIAL OFFICER LEITER 0 9 STATE FUND&CERTIFICATEOF DEPOSIT 010LOCALGOVT.MECHANISM 099 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 /> -71 CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.[-] 11.O 111. <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&SIGNATURE) TANK OWNER'S TITLE DATE MONTH/DAYNEAR <br /> DbL_a31 A n_ P n /O <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 11 JURISDICTION# FACILITY a,0 7 y <br /> m 231v 3 1 8 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT M -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> q la y <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 RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(6.95) <br /> a-Id q <br />