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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD •per e <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> _.. S76 d <br /> r•ll-on H• <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY LJ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL ED SITE <br /> ONE ITEM (� 2 INTERIM PERMIT 4 AMENDED PERMIT E] S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME p NAME OF OPERATOR <br /> PARCELII(OPTIONA <br /> ADDRESS NEAREST CROSS STREET L) <br /> CITY NAMEG(C��i STATE ZIP CODE S�/ <br /> ITE PHONE A W ITH AREA CODE <br /> CA /Y -- ' <br /> TO Box O CORPORATION O INDIVIDUAL O PARTNERSHIP LOCA DISTRICTS �COUNTY AGENCY I�STATE-AGENCY M FEDERAL-AGENCY <br /> TYPE OF BUSINESS a iGAS STATION 0 2 DISTRIBUTOR O RESEIRVATINDIAN <br /> ION YOF TANKS AT SITE E.P.A. I.D.Y(aplNnal) <br /> I 3 FARM O 4 PROCESSOR �l 5 OTHER OR TRUST LANDS <br /> jEMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LA$?.FIgAST) WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> '�,(,///!� /� <br /> PHONE Y WITH AREALGD <br /> NIGHTS: NAME(LAST,FIRST) L PHONE t WITH AREA CODE NIGHTS: NAME(LABT,FIR91) <br /> PHONE 0 WITH AREA COTIF <br /> R. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR S1AEE RE S ✓ bNbNdbHs 0 INDIVIDUAL E:3 LOCAL AGENCY O STATE-AGENCY <br /> Q CORPORATION O PARTNERSHIP 0 COUNtY-AGENCY l­__I FEDERAL-AGENCY <br /> CITY NAME 9T ZIP CODE PHONE 0 WITH AREA CODE <br /> I, <br /> /Ve� a v� G4 a sI'7S - - (9 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bm bink le INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> SII CITY NAME STATE ZIP CODE PHONE Y WITH AREA CODE <br /> J IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 it questions arise. <br /> TY(TK) HO 1414]-L/ L(dlQ-W <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY- (MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ Dox biMicale L7 I SELF-INSURED LJ 2 GUARANTEE � 3 INSURANCE O 4 SURETY BOND <br /> 0 5 LETTEROFCREDIT L_j B EXEMPTION F1 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal nolilicalion and billing will be sent to the lank owner unless or II is the d. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1. IL O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE;I$TR E AND CORCTECT <br /> APPLICANTS NAME(PRINTEDA SIGNATURE) APPLICANTSTITLE DATE MONTHIDAYNEAR <br /> i <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION N FACILITY R SQ 93 <br /> 31 I FF- I_ l <br /> /PL I2 <br /> - - <br /> TIONAL (CENSUS TRACT Y PTIONAL SUPVISOR DISTRICT CODE -OPTIONAL <br /> LOCATION CODE Op <br /> tg a3P 3 cD /4t <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 112 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS /i�� FOR0103A R9 <br />