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t60VM <br />STATE OF CALIFORNIA W P c <br />STATE WATER RESOURCES CONTROL BOARD +-,;,� •" v a <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A o; <br />O�t�f OPP� <br />COMPLETE THIS FORM FOR EAC ACILITYISITE <br />MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY LOBED SITE <br />ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT E] e TEMPORARY SITE CLOSURE <br />1—, nm^^&Ant crone <br />I. rALAL.11T1011C nYrvmm��ivnun.ev..w.+-a••,..... .."-.... <br />DBA RCILITY AME <br />__. <br />_-, <br />NAME OF OPERATOR <br />NEAREST CROSS STREET <br />PARCEL#(OPTIONAL) <br />AOOR SS <br />STATE ZIP CODE <br />SITE PHONE I`WITI4 AREA CODE <br />CITU NAME^ j <br />V`—I{vsc <br />CA <br />✓ BOXCORPOflATION D INDIVIDUAL 0 PARTNERSHIP <br />D LOCAL -AGENCY l� COUNTY AGENCY <br />O STATE -AGENCY l� FEDERAL -AGENCY <br />TOINMCATE <br />DISTRICTS <br />✓ IF INDIAN <br /># OF TANKS AT <br />SITE <br />E. P. A. I. D. # (optional) <br />TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR <br />RESERVATION <br />3 FARM O 4 PROCESSOR Q <br />S OTHER <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) tMtNUtRUT INN I NG I rrnavn (ocwi.vhn,). v,ivnu, <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE 9 WITH AREA COUP <br />II. PROPERTY OWNER INFORMATION - IMUST BE COMPLETED <br />�.—. A ,/L A G --A- I CARE OF ADDRESS INFORMATION <br />MAI OR STREETADVD`� S ✓ box tolnEic e = INDIVIDUAL = LOCAL -AGENCY 0 STATE -AGENCY <br />Q' ,-'1�� / //07 <br />/O7 CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY _ = FEDERALAGENCY <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS ✓ box b Intlkate = INDIVIDUAL O LOCAL'AGENCY O STATE -AGENCY <br />O CORPORATION (] PARTNERSHIP Q COUNTY -AGENCY FEDERAL AGENCY <br />CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE <br />IV. BOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMt3tH - Lail (yin) a43-utm N yuesnuns dose. <br />TY (TK) HQ 4 4 - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ Dox o ndkate l= I SELF-INSURED = 2 GUARANTEE 3 INSURANCE E_j 4 SURETY BOND <br />= 5 LETTER OF CREDIT E7] 6 EXEMPTION 43 OTHER <br />VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or 11 is checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. ❑ II. III. 0 <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />LOCAL AGENCY USE ONLY / L lu ID 4:0— <br />CIlO_OUmIINL-T1�(Y�I# JURISDICTION # FACILITY # <br />.,.... _.,... ..,.... ..,,T,...,.I ruim ie Toerla-nar�auel SUPVISOR-DISTRICTCODE OPTIONAL <br />I lJ� I �( Tyv I - <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION <br />FORM A (5-91) <br />�4J.�0 � <br />/ 7/7z- <br />UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />FOR0073A.5 <br />