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0 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE rn <br /> MARK ONLY .�1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> C-I3 s <br /> ADDRESS NEAR ST CROSS STREET PARCEL#IOPTIONAL) <br /> CITY NAME STATE ZIP CODq{'^ I SITE PHONE M WITH AREA CODE <br /> (< CA (/�VJl'o <br /> ✓BOX INCORPORATION 0 INOMDUAL O PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> I ownerol UST's a public agency,complete the tolbwn#name of supanimrc division.section oro6Ke which opemNs the UST <br /> TYPE OF BUSINESST'��1 GAS STATION ❑ 2 DISTRIBUTOR RESV IF INDIAN ERVATION #OF TANKS AT SITE E.P.A. I.D.k(optional) <br /> 4❑� 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> YDAYS: <br /> ��NAME(LAST,FIRST) y ONE#W(I�TH AREA CODE DA�YSyNTA,M�E( FIRST) PHONE p WITH A CODE <br /> 9/U—'IV ��— �� J�-lJ r £—L/c�C' hI <br /> NIGHTS: <br /> NAME(LAST,FIRST) ONE#WITH AREA CODE NIGHTS NAME( ,FIRST) PHONE#Wn HHAREA CODE <br /> �1' `l((� e7 V A 7(4 7 <br /> Il. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> AgCCI <br /> MAILING OR STREET ADDRESS ^' ✓ box toinicale O INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> C I CORPORATION ED PARTNERSHIP 0 COUNTY-AGENCY E:1 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE Pr # TH AREA CODE <br /> AL A 3 l 711+ - <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ttom�✓ boxlox�te CD INDIVIDUAL ED LOCAL-AGENCY O STATE-AGENCY <br /> Ay=11PORATION O PARTNERSHIP (1 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CIN NAME STATE ZIP CODE PHf E# TH EA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓CoxbiltliCdl9 �01 SELFINSURED 0 2 GUARANTEE 0 3INSURANCE 0 A SURETY BOND ED 5 LETnEROFCREDIr E::]6 EXEMPTION LJ 7 STATEFUND <br /> D 9 STATE FUND 6 CHIEF FINANCIAL OFFICER LETTER O 9 STATE FUND B CERTIFICATE OF DEPOSIT D 10 LOCAL GOVT.MECHANISM O 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: I.❑ 11, III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY F PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED B SIGNATURE TANKOWNER'S TITLE DATE MONTWDAYNEAR <br /> y 5- 2- <br /> LOCAL AGENCY USE ONLY rf 11 <br /> COUNTY# JURISDICTION# FACILITY# I ' <br /> m 771 1 ,510161 L,)l0 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL �4- ' '` <br /> THIS FORM M /�OWNERUST BE AMUSTMPANIED BY AT FILE THIS FORMW THE LOCAL AGENCY IMPLEMENTING THE UNDERGROL(1)OR MORE PERMIT APPLICATION- FORM B, WINFORMATION ONLY. <br /> TORAGE TANK REGULATIONS <br /> FORMA(6-95) <br />