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` s STATE OF CALIFORNIA 40 ^^`^� <br /> STATE WATER RESOURCES CONTROL BOARD o~o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE �.,ro <br /> MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO,E DY SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE �-- <br /> I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> o R LZf DriC..W <br /> ADDRESS <br /> NEAREST CROSS STREET PAflCEL#OPTIONAL) <br /> Seo a �0 u IeOQP Oo 7r 7 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> ,,C.h CA T�3 o ZO 82-o3-70 <br /> ✓ BOX Q CORPORATION Q INDIVIDUAL EPPARTNERSHIPIQ LOCAL-AGENCY Q COUNTRAGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> #Omar of UST is a public agency,complete the following:=9 d supereorol drrsion,seclbnWotan which eper4lN the UST <br /> TYPE OF BUSINESS t GAS STATION Q 2 DISTRIBUTOR Q ✓IF INDIAN p OF TANKS AT BITE E.P.A. I.D.It(optional) <br /> RESERVATION <br /> 0 3 FARM Q O PROCESSOR 0 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 N WITH AREA CODE <br /> 0+IuJIrLdvjL "Do 2-0370 YL Dftvo o b <br /> NIGHTS: NAME(LAST,FIRST) P NE N STH AREA CODES NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> JI3 Y c� <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ALwInD M I(c0 <br /> MAIIIN <br /> G <br /> ��O''RRv STREET ADDRESS ✓ Eosb iidrale Q INDMDUAL Q LOCAL-AGDICY Q STATE-AGENCY <br /> 10. / ANgr&N Po P Q CORPORATION PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGE14CY <br /> CITY NAMESTATE ZIP CODE PHONE#WITH AREA CODE <br /> 4-T'4po P ZA 30 tc797--0'37-f <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> I �LI�SI-1 D{-100 <br /> MAILING OR STREET ADDRESS ��j�^ .1Eoxtobdxale Q INDIVIDUALQ LOCAL-AGENCY Q STATE-AGENCY <br /> A N W Q CORPORATION PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE 21P CODE PH NE M WITH AREA CODE <br /> t 3 `i8 2-03 0 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [KK31jTUB <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED CLf//rn Jd2 y8j <br /> ✓boxMIndicate Q LSELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 1 SURETY BONG Q 6 LETTER OF CREDIT Q 6 EXEMPTION EXT T STATE FUND <br /> Q 6 STATE FUND&CHIEF FINANCIAL OFFICER LEITER Q 9 STATE FUND&cERnFICATEOF DEPOSIT Q /0 LOCAL GOVT.MECHANISM = 990THEfl <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.❑ 11.0 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&SIGNATURE) TANK OWNERS TITLE DATE MONTWDAYIYEAR <br /> A D /o <br /> LOCAL AGENCY USE ONLY <br /> COUNTY It JURISDICTION# FACILITY®Xp 7 y <br /> F7 2-3b �] a3 r 8 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 911819 <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 FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU STORAGE TANK REGULATIONS <br /> a -10, gq 6)�vz/5' <br />