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STATE OF CALIFORNIA • �� <br /> STATE WATER RESOURCES CONTROL BOARD +„� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ee , <br /> � COMPLETE THIS FORM FOR EACH FACILrTYISITE °•�„o,,.'^ <br /> MARK ONLY [o/t NEW PERMIT 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION E] 7 PERMANENTLY SITE <br /> ONE REM Q 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAMEOFOPERATOR ^� <br /> w4 LA i� t t ko Ls <br /> ADDRESS NEAREST CROSS 9TqEET PARCEL a(OPTKINAU <br /> 3SSd S tJ t cr-r u-tcr <br /> CITY NAME C STATE bP CODE SITE PHONE s WITH AREA CODE <br /> CA `jSZli' 4kfr-9L[ <br /> T 10 NqC TE LTJ CORPORATION 0 INDIVIDUAL =PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> •1 owner of UST Is publicagency,m late the follow) DISTRICTS' <br /> p np following:name of Supervisor of tlNisbn,stenion,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATK)N Q 2 DISTRIBUTOR ✓ IF INDIAN IN OF TANKS AT SITE E.P.A. I.D.If(optional) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR d5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> eLcccS{ta- 47— <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> i c�o✓t Mike B1 -33 L <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Y\d. L M <br /> MAILING OR STREETAD RESP C ✓boxfolrfta Q INDIVIDUAL = LOCAL AGENCY O STATE-AGENCY <br /> 0, I p ZO CORPORATION [if PARTNERSHIP = COUNTY-AGENCY 0 FEDERAL AGENCY <br /> CITU NAME STATS ZIP CODE PHONE a WITH AREA CODE <br /> WAzn cu C 9S"33� zoL)yc�z-z3by <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Ir opi5 <br /> MAILING OR SITREET ADD S Wes* <br /> LL� ,+ (( �✓y box bini O INDIVIDUAL 0 LOCAL O STATE AGENCY <br /> �K FY'C4r. W T C\✓cle- CkMRPORATION EJ PARTNERSHIP Q COUNTY-AGENCY a FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> 9-sz06P 247 Yg - 41z <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-T4--] 0 ? ( W <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boxbiMbaN = 1 SELFINSURED 2 GUARANTEE 3 INSURANCE E73 4 SURETYSOND <br /> 0 5 LETrEROFCREDIT Q 6 EXEMPTION L] %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.❑ 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 /> OWNER'S NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTWUAYNEAR <br /> LOCAL AGENCY USE ONLY DG 0 O <br /> COUNTY# JURISDICTION If FACILrrY t,6o`7Q13d <br /> 3 4 <br /> LOCATION CODE -OPTIONAL CENSUS TRACTa -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 INFORMATION 0!A (,t t9 G <br /> FORMA(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />