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STATE OF CALIFORNIA �" • ' op <br /> STATE WATER RESOURCES CONTROL BOARD z. <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A <br /> C ETE THIS FORM FOR EACH FACILrrY/SITE <br /> MARK ONLY ❑ I NEW PERMIT llf 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM a 2 INTERIM PERMIT O d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAM9 NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 3� <br /> CITY NAME STATEZIP CODE SITE PHONE#WITH AREA CODE <br /> L.L-1Zn CA !� <br /> I <br /> TO OC TE CO PoRA110N INDIVIWAL O I/ Box PARTNERSHIP 0 LOCAL-AGFNCY 0 COUNTY AGENCY 0 STATE-AGENCY 0 FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O I GAS STATION E:] 2 DISTRIBUTOR ED gIF ESERVNDIIAN ON N OF TANKS AT SITE E.P.A. I.D.N Ioptimaq <br /> Q 3 FARM Q a PROCESSOR E0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> /�i L-,ES (may — tYY cunur a Wrcu ARce ronF <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> $ Lt rn.( SG. ..ti.e— <br /> PHONE f WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME /� ETCARE OF ADDRESS INFORMATION <br /> f/ <br /> MAILING ORSTREADDRE bab 0INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> Q/ 7EV CORPORATION Q PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> IlletlZ f ! 64 S <br /> III. TANK OWNER INFORMATION- MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> _ • 7+ G 2 <br /> jV _727— <br /> MAILING OR STREET ADDRESS• ✓ boa b IMbale I] INDIVIDUAL 0 LOCAL-AGENCY STATE AGENCY <br /> S fc u li v2i P O CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME - STATE ZIP CODE PHONE#WITH AREA CODE <br /> a <br /> IV. BOARD OF E N UST A ACCOUNT NUMBER-Call(916)323-9555 it questions arise. <br /> TY(TK) H 4 447- 61 2 <br /> V. PETRO LEU RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THEMETHOD(S) USED <br /> ✓ bot biMkale I� I SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> 0 5 LETrEROFCREDIT O 6 EXEMPTION 0 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 cqpdlzed. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 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 /> APPLICANi'G NAME(PRINTE08 SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It FACILITY# 61q ISO CL4 <br /> 131181 ❑M �i .�I�l <br /> --- --- <br /> LOCATIONCODE OPTIONAL (CENSUS TRACTN -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 6 3 " a3 C 314Y19 <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(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> /'. FOR0033A-R6 <br />