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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> i� <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENJCLOSSI <br /> ONE ITEM 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 3\ <br /> DBA OR FACILITY NAME J NAME OF OPERATOR <br /> \ I <br /> AD RESS �\ 1 NEAREST CROSS STREET PARCEL#(OPnONAL) <br /> CI NAME 11 W STATE LP CODE SITE PHCNE#WRH AREA CODE <br /> CA 95 f�C� <br /> ✓BOX 5KCORPORATION INDMDUAL O PARTNERSHIP F-1 LOCAL-AGENCY COUNTY-AGENCY' E:1 STATEAGENCY' D FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> I oarerof USTa a xSic agency,c m Vele the fo9owhT none of SUP9PA T01 di icon,section croft w iol op WO 9la UST <br /> TYPE OF BUSINESS ® 7 GAS STATION E::] 2 DISTRIBUTOR � REV IF INDIAN <br /> R OF TANKS AT SITE E P.0. L D.#(optional) <br /> ❑ 3 FARM Q e PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST <br /> -(' S _ T` PHONE) ,q-7q <br /> q-7 EACODE-753� DAYS: NAME(LAST.RpSn `E `W i H� � TtFi'F7 A CODE <br /> �3�7 <br /> NIGHTS'�r//. NAME(LAST FIRST) -' 11�C.lL�f ONE+1 WITH AREA CODE NIG TS: E(/LArd'ST1/,/!-YRI l�� ONE a WUI/TH AREA CODE a <br /> II. PRF17OPPIJERTY OWNER INFORMATION-!'((MUUUST B/_/E/ COMPLETED) <br /> ((7(�V 7�\rl /7/ r�J[7 <br /> NAME y On IJ I CARE OF ADDRESS INFORMATION <br /> M�� <br /> MAILING OR STREET ADOR SS l I•y"t.L' ✓ bosh Y7cate 0 9DMDUAL E3 LOCAL AGENCY E:1 STATE-AGENCY <br /> `S(S(J (N r' 1 Q CORPORATION ED PARTNERSHIP COUNTY-AGENCY 0 FEDERALAGENCY <br /> CITY <br /> STATE ZIP CODE ���HONE# AREA CODE <br /> �� <br /> � � /W <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOFOW ER cin) l CARE OF ADDRESS INFORMATION <br /> M 2r2 r <br /> MAILI OLgSTREET ADO ESS I c 1-I ✓ boxla egrate Q NDMDUAL O LOCAL-AGENCY STATE-AGENCY <br /> ( J� MI �I C' � Lj I�CORPORATION = PARTNERSHIP ED COUNTY-AGENCY FEDERAL-AGENCY <br /> CITYN __ \ STZIP�OOE_ OS C1W TH AP q PHONE a CODE <br /> ��r C 75 3 1 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER/-Call(91(6))33222--9669 if questions arise. <br /> TY(TK) HO 4 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box t hboale O 1 SELF-INSURED p 2 GUARANTEE Q 3 INSURANCE =a SURETYBOND 0 5 LE TEROFCREDR =6 EXEMPTION O 7 STATEFUND <br /> Q 8STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERPRCATEOFDEP06n O 18 LOCAL GOVT.MECHANISM O99 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 /> TANKOWNE 'S NAMF,,.(BRINTE SIGNA E) TANK OWNER'S TITLE DATE MONTWDAYNEAR <br /> I � Jkt 111111 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION# FACILITY M <br /> m <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 FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(6-95) <br />