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'yboua ea <br /> 0 STATE OF CALIFORNIA 'i. <br /> STATE WATER RESOURCES CONTROL BOARD 3�. <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �e <br /> „ lrs , o' <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME / NAMEOFOPERATOR <br /> /J/ <br /> ADDRESS NEAREST CROSS STREET PARCEL M(OPT)ONAU <br /> —2/3 £. 7— lc2- <br /> CITY NAME STATE ZIP CODE SITE PHONE x WITH AREA CODE <br /> .510 CABOX <br /> 9S 20� <br /> TO INDICATE O CORPORATION E�I INDIVIDUAL O PARTNERSHIP LOCAL AGENCY I1=1 COUNTY-AGENCY O STATE-AGENCY O FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTORO ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.;(optional) <br /> RESERVATION -� <br /> 3 FARM 0 4 PROCESSOR OTHER OR TRUST LANDS [/\ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRSI) PHONE;WITH AREA CODEDAYS: NAME(LAST,FIRST) <br /> r�� 209 Y�3- 77 sem. o <br /> NIGHTS: NAME FIRST) PHONE;WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> G 7 <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME /� t,/ <br /> � Lc CARE OF ADDRESS INFORMATIFl� ON <br /> `CU / /eL 57&0s1 u��A <br /> MAILING OR STREET ADDRESS / ✓ hoxblMkal9 INDIVIDUAL E71 LOCAL-AGENCY Q STATE AGENCY <br /> 3 S TR / 0 CORPORATION O PARTNERSHIP E-1 COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME SK7L/GIVE STAT�F _ ZIP CODE�ZU� PHONEA WITH ARECCOD� 779J <br /> III. TANK OWNER INFORM(ATION-(MUST BE COMPLETED) (� !y n( (, LJ <br /> NAiEO NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREE�gQDREESSS; �O X �S �� ✓ box 0 MioaW INDIVIDUAL 0 LOCAL-AGENCY [� STATE-AGENCY/ D CORPORATION I1 PARTNERSHIP 0 COUNTYAGENCY D FEDERAL-AGENCY <br /> CITY NAMEJ �� STA^ ZIP COOS PHONE;WITH AREA DODE <br /> iT ys z�s S-0 �YC 3 -7 7f <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ L414 1- 6 3 2 L <br /> V. PETROLEUM UST FINANCI RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box biMicate Ftn 1 SELF-INSURED 2 GUARANTEE �,' 3 INSURANCE 0 4 SURETY BOND <br /> =1 5 LETTEROFCREOIT 0 6 EXEMPTION L, IN 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.❑ 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 B SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY; JURISDICTION It FACILITY; PIIUA Sa I <br /> 3, `1 <br /> 77 G D <br /> --- -- -- <br /> LOCATION CODE OPTIONAL CENSUS TRAT;cOP TIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> V 013S-I) d-3 CO 310, 113 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR6W]A afi <br />