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A <br /> STATE OF CALIFORNIA A ter. cr <br /> z <br /> STATE WATER RESOURCES CONTROL BOARD ., <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> b <br /> Vs ! d o <br /> �- cel lRgfe Nth <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED <br /> ONE ITEM L❑ 2 INTERIM PERMIT n 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �j <br /> L FACILITY/SITE INFORMATION & ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> A IUD_ _ 2-If- , OaLL <br /> ADDRESS NEAREST CROSS STR E PARCEL#{OPTIONAL) <br /> P48A r LnAtF _ MaR9b q LrJ 69b -74D-40 ro <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> TO INDICATE L CORPORATION fip&IND�V DUAL 7 PARTNERSHIP LOCAL-AGENCY ® COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> fifesIR DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR ,/ IF IND9AN'#OF TANKS AT SITE E.P.A. I.D.#(oplianat) <br /> RESERVATION <br /> F 3 'FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> D S: NAME ST �ST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) f-41�_/ ARF—A C3(}CS✓F, 7 <br /> j� L PHONE#WITH <br /> NIGHTS: NAME(LAST, ;jTj PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> _ <br /> 14 A4&C RHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM CARE OF ADDRESS INFORMATION <br /> voba&-li ki 100 gAxi "8UejAUF_mrLAmm <br /> MAILING OR STREET ADORESS ✓ bcxmindicata INDIVIDUAL I_] LOCAL-AGENCY 0 STATE-AGENCY <br /> W _<a- ` Rum Ufa 1/ru � /EiZ 0 CORPORATION 0 PARTNERSHIP I� COUNTY-AGENCY E] FEDERAL-AGENCY <br /> !CITY NAME !+f u�+7 �.++- ` STATE ZIP CODE PHONE#WITH AREA CO E <br /> III. TANK OWNER INFORMATION- (MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> v' box to indicate © INDIVIDUAL LOCAL-AGENCY I 1 STATE-AGENCY <br /> 0 CORPORATION = PARTNERSHIP COUNTY-AGENCY n FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 i6 questions arise. <br /> TY(TK) HQ 14_L4 i'- 6 � O 7 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY- (MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box tomdicalc 1 SELF INSURED C 2 GUARANTEE 1 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT 0 6 EXEMPTION X 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 checked. <br /> [CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ IPW III. <br /> THIS FORM NAS SEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPL NAME(P ED&S N RE) APPLICANTS TITLE DATE MOWHOAYNEAR <br /> LOC L AGENCY USE ONLY <br /> COUNTY# JURISDICTION# <br /> OGATION CODE OPTIONAL CENSUS TRACT# OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> . t o a— <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PE$MIT A LI ATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, <br /> FciRrsA;1z.A1, FILE THIS FORM WITH THE LOCAL AGENCYI6lP INGTHEUNDERGROUNDSTORAGETANKREGULATIONS <br /> /�� '�T'j'{ OA0037A R6 <br />