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�✓ STATE OF CALIFORNIA sc'. <br /> STATE WATER RESOURCES CONTROL BOARD ;ye,� +e <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A en _ <br /> COMPLETE THIS FORM FOR EACH FACILITlISITE m <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE <br /> ONE fTEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME ,p (� NAME OF OPERATOR <br /> citADDRESS R ^D NEAREST CROSS STREET PARCELt(OPTIONAL) <br /> 7 .5L T Y�L Fi <br /> CITU NAME STATE ZIP CODE SI E PHOWE#WITH AREA CODE <br /> v� CA 5 (Zoct S 3m— 14 Z Z <br /> ✓BOX CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY' O STATE AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE I DISTRICTS <br /> 'ff Merol UST6a PabkagelxY.mm MotheblbwhW-M1YII oolsIRINVI5MCf4Nision, OLIN woffiLe MtI UP6l8IE5111e UST <br /> TYPE OF BUSINESS I GAS STATION ❑ 2 DISTRIBUTORO ✓IF INDIAN NOF TANKS AT SITE E.P.A. I.D.t(optional) <br /> RESERVATION <br /> 0 3 FARM O 4 PROCESSOR O S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) u- DE <br /> P� E k W ITH AREA CODE// DAYS: NAME(LAST,FIRSATI `�— PN�y N 212�AREA Q/I <br /> NIGHTS: NAME(LAST,FIRST) PH E#WITH AREA CODE NIGHTS: NAME(LAST�NFIRST) P ONEJ WITH AREA CODE <br /> Iooh Z31- 66 23 Cil" ra+ � 8ov�23(—QS z3 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> c. S'09, <br /> MAILINGORSTREETADDRESS ✓ box ton to Q INDIVIDUAL l� LOCAL-AGENCY (] STATE-AGENCY <br /> 24¢ S^4 , CORPORATION O PARTNERSHIP (] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE P NE#WITH AREA CODE <br /> 54a,,._ Fri--C b CA 94 to S <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESSINFORM ON <br /> MAILING OR STREET ADDRESS ✓ �xio^tie D INDIVIDUAL O LOCALAGENCY O STATE AGENCY <br /> p )( �X CORPORATION O PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE P NE# TH AREA CODE <br /> .e 649 5 3 925 <br /> g+2- <br /> IV. <br /> 42IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 74F4-1-16 3 11 17 1 / 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bor to iM'raU <br /> I SELF-INSURED L_�] 2 GUARANTEE O 3 INSURANCE 0 4 SURETY BOND Q 5 LETTEROFCREDn =6 EXEMPTION O T STATE FUND <br /> O6STATE FUND&CNIEFFINANCIAL OFFICER LETTER E:] 8STATE FUND BCERTIFICATE OFDEPOSIT E:J 10 LOCAL GOVT.MECHANISM O990THER <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: 1.❑ It.❑ III. 7 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT 7jf <br /> NAME(PRINTED&SIGNATU E) T`A&W B NER`S IT(LE DATE OUT DAYNEAR7 77W <br /> q <br /> JCA✓ �e�J \ ro ^6✓J �^—^— Io L 8 qi{ <br /> LOCAL AGENCY USE ONLY <br /> COUNTY It JURISDICTION# FACILITY N <br /> FTI <br /> LOCATION CODE OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 /> OWNER MUST FILE THIS FORta`KITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROI IMO STORAGE TANK REGULATIONS <br /> FORM A(6-95) <br />