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t� <br /> r NO, <br /> STATE OF CALIFORNIA c'S <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> MARK ONLY ez T NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANEN CLOS SITE <br /> ONE REM (] 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> land Wore # 1 4 dtEAlan'CROS;t Ca vj <br /> ADDRESS NRES SSTREET PARCEL N(OPTIONAQ <br /> 5o( N. ershi Avenue Mang rare <br /> CITY NAME STACODE <br /> TE 21P�D � S�� AFA�745 <br /> 5toG to <br /> ✓ BOX CORPORATION Q INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY O STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 'Xo of USTisapbticagwq.m WOOte MIbw W re 0d Su r mrdd ision,seclgn wolre:e eltich o"Wes the UST <br /> �� t ✓IF INOIAN N OF TANKS AT SITE E.P.A. I.D.N(aptioneq <br /> bGlrr GAS STATION 2 DISTRIBUTOR O RESERVATION <br /> TYPE OF BUSINESS <br /> 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAM�( AST,FIRST) PHON H AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> %afr �Ilr 07-�2[da <br /> NIGHTS: NA E(LAST,FIRST) N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> drr t P201 N( OI2�7 d2ivf� <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF tDDRESS INFORM TION <br /> NLINGORSTREET ADD ESB ,y ✓ bmtUndrate f� INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> z , l �� H � wit 4T 1 ORPORATION =PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITYDN JMCE_ t ��%L��LL^^ STATE ZIP CODE PHONE N WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) LY G �U%J <br /> N EOFQy+NtXER C FADDRESSINF RMATION <br /> SIT jQAd (pr ajtL)1 EOb Iv1n <br /> MAILING OR STREET ADDRESS ✓ bos to ibirate Q INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> OQx 1 I CORPORATION O PARTNERSHIP 0 COUNTY AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE WITH AREA CODE <br /> 172112 X 7r�ZZ 1 -0711 z' Z-55 - 2Z-51 <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 /> ✓Ws to mCcak D 1 SELF INSURED [=]2 GUARA O 3INSURWCE E__1 4 SURETY BOND 05 LETTER OF CREDrr Q 6 EXEMPTION O 7 STATE FUND <br /> � 8STATE FUND&CHIEF FINANCIAL OFFICER LETTER 09 STATE FUND&CERTIFICATE OF DEPOSIT I= 10 LOCAL GOVT.MECHANISM = 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 <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 it.O III.[vll <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT �v <br /> TANK OWNERS NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAYNEAR <br /> �,�- rj9 t�,ho l 4 <br /> lH - c' EX <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N FACILITY N 111 11 <br /> 0^ �l <br /> LOCATION CODE -OPTIONAL CENSUS TRACT N -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 2 IIt <br /> THIS FORM MUST BE ACCOMPANIED BY AT l FAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FOR. H THE LOCAL AGENCY IMPLEMENTING THE UNDERGRC STORAGE TANK REGULATIONS <br /> FORM A(6-95) `4111111, letter <br />