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Af <br /> • <br /> STATE OF CALIFORNIA • "°`�oA C <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNpERGROUND STORAGE TANK PERMIT APPLICATION • FORM A a o <br /> ��IaIA� � • ,� a <br /> COMPLETETHIS FORM FOR EACH IIJTY/SITE "•°""'• <br /> MARK ONLY [] I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E—] ] PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT E a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAM // .a// NAME OF OPER <br /> ADDRESS ATOR <br /> LIU S {YI• NNUV La7lp S <br /> p NEAREST CROSS STREET PARCEL 0(OPFIONAq <br /> CITY NAME ( 3 S <br /> _T40 L�C FT/yt STATE ZIP CODE SITE PHONE*WITH AgEA CODE <br /> ✓ sox CA <br /> TO INDICATE 0 CORPORATION O INDIVIDUAL Q PARTNERSHIP (]LOCAL-AGENCY 0 com-Y-AGENCY D STATE-AGENCY <br /> DISTRICTS C� FEDERAL-AGENCY <br /> TYPE OF BUSINESS O I GASSTATION Q 2 DISTRIBUTOR ✓ IF INDIAN10 <br /> a OF TANKS AT SITE E.P.A. I.0.#(oplionap <br /> 0 3 FARM O 4 PROCESSOR 5 OTHER =OR TRUSTTVLAND I S <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> L S .Lvy. - 2 S G "•,np <br /> NIGHTS: NAME(LASTFIRST) PHONE?WITH FLEA CODE NIGHTS: NAME(LAST,FIflSTtWITH AREA COOP <br /> .S LI ^_4— <br /> C4 lv1R <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME <br /> ^/G CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET AD/DRESS ✓ Fwr bintlbale <br /> p /� q D INDIVIDUAL l� LOCAL-AGENCY �STATE AGENCY <br /> / (2 0nX 7GY / CORPORATION � PARTNERSHIP (] COUMKAGENCY <br /> CITY NAME - Q FEDERALAGENCY <br /> NG ST TE ZIP CODE PHONE?WITH AREA CODE <br /> 6 <br /> -7ly- 97s <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> L <br /> CARE OF ADDRESS INFORMATION <br /> S r <br /> ET ADDRESS• ✓pox minOicam <br /> Q INDIVIDUAL 0 LOCAL-AGENCY (] STATE-AGENCY <br /> Ste- M� D CORPORATION I� PARTNERSHIP 0 COUNPFAGENCV FEOERALAGENCV <br /> STATE ZIP CODE PHONE x WITH AREA CODE <br /> $q �[ A o <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HO L4141- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box m indicate [] I SELF-INSURED 2 GUARANTEE <br /> 3 MTHER E 4 SUREIY BOND <br /> LD 5 LETTEROFCREOIT <br /> O 6 EXEMPTION � %OHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is c ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> I. II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE <br /> DATE MONTWDAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 3 y : _ _ -rN�v Sy3 <br /> LOCATION CODE OPTIONAL (CENSUS TRACT? -OPTIONAL SUPVISOfl- <br /> DISTRICT?ODE -OPTIONAL <br /> /Z / 3�dyly <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 /> FORM A(12x90 FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 0 0 <br /> FORD033A R6 <br />