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STATE OF CALIFORNIA •n`; <br /> STATE WATER RESOURCES CONTROL BOARD �" <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� =° <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION E:j ] PERMANENTLY CLOSED.SITE <br /> ONE ITEM O 2 INTERIM PERMIT Q 0 AMENDED PERMIT 5 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR t <br /> U�ckI - / r ina moi !au Po��s <br /> ADDRESS NEAREST CROS STREET PARCEL N(OPTIONAL) <br /> 707 E, emrl�tAAve, Wash <br /> in �H <br /> CITY NAM STATE ZIP O S TE PHONE M WITH AREA CODE <br /> t�T� CA <br /> .Ip <br /> ID 33 20 23 - i5 /a <br /> ✓BOX CORPORATION INDNIDUAL O PARTNERSHIP O LOCAL-AGENCY f�COUNTY-AGENCY* O STATE-AGENCYFEDERAL-AGENCY* 5 <br /> TO INDICATE DISTRICTS <br /> 8 ovou rut UST's a Wb4c a9enry,conglete the tollmii¢iwna of npvmrd dMbion,secto orotru Aicti Freon to UST <br /> TYPE OF BUSINESS1 GAS STATION Q 2 DISTRIBUTOR O ✓IF INDIAN MOF TANKS AT SITE I E.P.A. I.D.N(opdanaO <br /> I�dt <br /> 1 RESERVATION <br /> Q 3 FARM Q & PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODEDAYS: NAME(LAST,FAS PHONE M WITH AREA CODE <br /> an ur&ao (2 of/823-4/Sq /'cv�fe �'Z3 -9i <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> C Pow10a C2o <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMTPLFTFD) <br /> N ME ) CARE OF ADDRESS INFORMATION <br /> Y a fe p,) <br /> MAILING OR STREET ADORES p� ✓ %c">�-=�''- I401YIWAL OLOCA4AGENCY STATE-AGENCY <br /> D D�vn 6 V Ave- 0 CORPORATION O PARTNERSHIP COUNTY AGENCY FEDERAL-AGENCY <br /> CI STATE ZIP CODE PHONE M WITH AREA CODE <br /> N <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) ((Y✓r <br /> NAME OF OWNER t S6A �/YI T ^_"!/IQ 14 AGn-AeS CARE OF ADDRESS INFORMATION <br /> M ( GOR STREETADDR ✓ baxtoodksle len INDIVIOUAL OLOCAL-AGENCY OSTATE-AGENCY <br /> D - S ��ni CORPORATION O PARTNERSHIP f�COUNTY'-AGENCY I] FEDERAL-AGENCY <br /> CITY NAMEI/^�/^/ ® STAT ZIP CODE PHONE N WITH AREA CODE <br /> / • / �G- <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4—R - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boe bind'cele O 1SELF-INSURED O 2 GUARANTEE O3 INSURANCE =1 SURETY BOND O 5 LETTER OF CREDR O 6 EXEMPTION Q T STATEFUIO <br /> O8STATE FUND&CHIEF FINANCIAL OFRCERLETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT O10LOCAL GOVT.MECHANISM = 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: I.0 it O III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> T KOWNER'SNA (P IN D& GNATU TA NK OWNER'S TITLE DATE MONTHrDAYNEAR <br /> Q 476,f <br /> 6-117 1 <br /> LOCAL GENCY USE ONLY <br /> COUNTY N JURISDICTION It FACILITY# p'(S ai <br /> I 6 0 S7 / <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LFAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(695) OWNER MUST FILE THIS FORIrlI.fi THE LOCAL AGENCY IMPLEMENTING THE UNDERGR01`.I,,II4TORAGE TANK REGULATIONS <br />