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'F_S 'p6W0 [ <br /> STATE OF CALIFORNIA — ^� ; <br /> STATE WATER RESOURCES CONTROL BOARD i ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE [.�„a�,;.' <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ED2 INTERIM PERMIT 0 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE y <br /> I. FACILITY/SITE INFORMATION 6 ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITYNAME NAME OF OPERATOR <br /> r7 Id <br /> �7�'Ohs <br /> ADDRESS NEAREST CROSS STREET PARCELe(OPrxMgL) <br /> 3 �- c�vT1 c�6z.- 06o- <br /> CITYNAME STATE ZIP CODE I JSITE PHXWEa WITHA <br /> ✓ lax <br /> TO INDICATE O CORPORATION INDIVIDUAL PARTNERSHIP LOCAL AGENCY O CWNfYAGENCY' I�STA7E-AGENCY' <br /> 'ff owner d UST b a pubic agency, ,DISTRICTS' Q FEOERALAGENCY <br /> complete the lollawing:name d Supervisor d dWbbn,section,DISTRICTS' <br /> office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR ' IF INDIAN a OF T ATSITE E.P.& I.O.S tIcta nap <br /> 0 3 FARM Q A PROCESSOR 5 OTHER O RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAVS:WNAME LAST,FIRST) PHO E e WIT REA DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> r � 9 3 <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WIH AREA NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME� <br /> � �T�L A �.�i'S CARE OF ADDRESS INFORMATION <br /> MAILING ORSTREETADDRESS AVV�GG �• ✓Ew bNdbaN 0 INDIVIDUAL I� LOCAL AGENCY I1 STATE AGENCY <br /> 0 T r �-ra r� O CORPORATION O PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CITU NAME STATEZIP CODE PHONE A WITH AREA CODE <br /> v cyY t� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING ORSTREETADDRESS b bol <br /> 3 3m> / ^ ✓bw CaM = INDIVIDUAL O LOCAL-AGENCY I1 STATE-AGENCY <br /> ��� (/� 0 OORPORATNXI = PARTNERSHIP F-1 COUNfVAGENCY D FEDERALAGENCY <br /> CRY NAME STATE 21P CODE I PHONE a WITH AREA CODE <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 /> ✓Dox bbdwb 1 SELF-INSURED E]2 GUARANTEE 0 3 INSURANCE <br /> O 5 LETTEROFCREOIT =6 EXEMPTION I�W OTHER A SURE YBONG <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. to <br /> It.a <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAN CORRECT <br /> OWNER'S NAME(PRINTED a SIGNED) OWNERS TITLE DATE MONTKOAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> C��a JURISDICTION It FACILfTYtW7G8 Ems' <br /> aIli I) a s 6 <br /> LOCATION 3DE -OPTIONAL CEfjl�ll�• Ti •op"ou L 9UWISOR-DISTRK:T CODE -(WTpNAt <br /> THIS FORM MAST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORMS,UNLESS THIS 1S A CHANGE OF TION ONL <br /> FORM A(3/83) <br /> OWNER MUST FILE THIS FORM WITH"1E LOCAL AGENCY IMPLEMENTING THE UNDERGROUND F--cIAGE TANK REGULATIONS <br /> POPALUM <br />