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qP <br /> STATE OF CALIFORNIA '� ounces <br /> STATE WATER RESOURCES CONTROL BOARD " <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ <br /> ONE ITEM 7 PERMANENTLY CLOSED SITE <br /> ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 0 I <br /> DBA OR FACILITY NAME <br /> NAME OF OPERATOR � D <br /> ADDRESS I � <br /> .2-3 <br /> 56� WA—ii <br /> a W�L! /� i i�Cjo p NEARS§T CROSS STREET PARCEL 1(OPrfONALj <br /> CITY NAME [. r <br /> <�z C-'j v f STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> II/ BOX <br /> �__/ CA 2_4, 2-go -� <br /> CORPORATION [�INDIVIDUAL �v PARTNERSHIP <br /> 7O INDICATE E:] LOCAL-AGENCY C:1COUNTY-AGENCY' � STATE-AGENCY' <br /> towner of UST s a pubic agenDISTRICTS <br /> cOmPlef8 the following:name of supervisor of division,section or office which operates the UST FEDERAL-AGENCY' <br /> TYPE OF BUSINESS 7 GAS STATION <br /> 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 4 PROCESSOR5 OTHER RTRUSTVLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) optional <br /> E <br /> NAME(LAST,FdRST) PHONE#WITH AREA CODETkLl DAYS: NAME(LAST,FIRST) PH NE#WITH AREA CODE <br /> C� NC7�-TrV /. T/ 11U �SS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) ® — <br /> FNAE ' CARE OF ADDRESS INFORMATION <br /> OR STREET ADDRESS ✓ box to n�eale„`�, 5 ) j ,�, ,(7r „�i �� 0 103VID0 L Q LOCAL-AGENCY QSTATE-AGENCYE 11 L 4 T d' Q CORPORATION PARTNERSHIP �I COUNTY-AGENCY Q FEDERAL-AGENCY <br /> + STATE ZIP CODE PHONE#WITH AREA CODE <br /> STZ3 C f+j s5 a o C <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> K-4 l h_ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS [� <br /> ��� ^ A ✓ box to indicate i D INDIVIDUAL i� LOCAL-AGENCY <br /> lJ f� t�, I� STATE-AGENCYLAGEN <br /> ®CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> GrrY NAME srgrE ZIP CODE <br /> C7 �"T7 ( PHONE#WITH AREA CODE <br /> 1 CJ el 111, ��C/ <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call (916)322-9669 it questions arise. <br /> TY(TK) HQ 44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box 10 indicate 0 1 SELF-INSURED [] 2 GUARANTEE ED 3 INSURANCE 0 4 SURETYBONo 0 5 LETTEROFCREDIT [_1 6 EXEMPTION 0 7 STATE FUND <br /> []li STATE FUND&CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND&CERTIFICATE OF DEPOSIT L:71 10 LOCAL GOVT.MECHANISM 7-71 99 OTHER <br /> V1. 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: L❑ II. Ill. <br /> TN1S FORM NAS BEFN COMPLETED UNtlER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT <br /> =TANKOWN—ERS NAME(PRINTED&SIGNATURE) TANKOWNER'STITLE� DATE MON7Hi0AY/YEAR <br /> LOCAL AGENCY USE 0 Y <br /> COUNTY N JURISDICTION N FACILITY N G� <br /> LOCATION CODE -OP710NAL �CENSUS TRACT# -OPTIONAL <br /> ] UPVISOR-DISTRICT CODE •OPTIONAL <br /> 2 7 25r cf <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(6.95) OWNER MUST FILE THIJNM WITH THE LOCAL CY IMPLEMENTING THE UNDEWUND STORAGE TA GULATIONS <br />